June 13, 2016 Ask Owen

Training & Customization: The Keys to Improving EHR Usability

Education concept: Training on computer keyboard background

At the annual Healthcare Information and Management Systems Society (HIMSS) conference in March 2016, Andy Slavitt, acting CMS administrator, revealed the worst kept secret in healthcare: Physicians are extremely frustrated with current EHR systems.

During a keynote speech, Slavitt shared findings from eight focus groups CMS conducted with frontline physicians on EHRs. The main theme was that EHRs were not intuitive and usable for a physician’s work flow. One doctor interviewed by CMS complained that it took eight clicks to order aspirin in the EHR, and it took 16 to order full-strength aspirin.

The dislike for EHR systems, especially in terms of usability, has been boiling for several years. According to a survey conducted by the AMA and American EHR Partners, a research company which rates vendors in the space, satisfaction with EHR systems among physicians dipped nearly 30 percentage points from 62 percent in 2010 to 34 percent in 2014.interoperability

“Current EHRs take too long to enter data, require we enter a number of things that do not seem to be valuable for patient care, are designed to fulfill federal programs rather than the needs of the physicians and the patients using them, and they don’t display information in a way that’s as usable and helpful to doctors as it should be,” Steven J. Stack, an emergency physician in Lexington, Ky., and the president of the AMA, told Physicians Practice. “The final thing is they don’t talk to each other. One of the big reasons to widely deploy EHRs was to share information across different sites of care and clinicians, and they simply don’t do that at a widespread level.” Stack also confirmed the click problem mentioned by Slavitt in the speech at HIMSS. He says one of his colleagues at AMA told him it took 20 clicks to order a flu shot. “That is not streamlining or making my life more efficient as a physician,” he says.

Thomas Kuhn, senior systems architect for health policy and regulatory affairs at the American College of Physicians (ACP), says the reporting requirements for programs such as Meaningful Use require physicians to document data they wouldn’t otherwise pay attention to when caring for a patient. Robert Wachter, physician and professor and interim chairman of the Department of Medicine at the University of California, San Francisco (UCSF) as well as the author of “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age,” says the core problem is EHRs were not built with usability in mind or an appreciation for a physician’s work flow. Moreover, he doesn’t think it’s a coincidence that higher rates of physician burnout have correlated with widespread EHR adoption.

It would be one thing if an unusable EHR was just a pain in the neck for physicians. As Wachter says though, these EHR-related work flow issues can lead to bigger problems. “The most disturbing thing [that can happen] are major medical mistakes … They happen all the time. In analyses of medical errors, it’s clear that the category of EHR-facilitated mistakes has become very large,” he says.


While it’s fair to say there is a lot of negativity and legitimate concerns surrounding current EHR systems, Kuhn says they can be customized to fit providers’ needs. Others, like Wachter, agree; he has seen it at his own organization. “At UCSF, we have put a lot of resources and smart people [to work]… their job is to look at how the system is working, hear the feedback, learn from the errors, and reconfigure to make it better and more efficient,” he says.

This may work for a large organization like UCSF, but what about smaller practices without those kinds of resources? Configuring the EHR to make it more usable is a possibility there too, says Auren Weinberg, a pediatrician at the eight-physician, Lower Bucks Pediatrics in Yardley, Pa. “Physicians have to look at the 10 to 20 most-common things they do in an EHR. Every EHR we’ve ever had … had the ability to script those types of events in the chart in a way that minimizes clicks. What most physicians are doing are taking the EHR out of the box and trying to work with it. That is the worst way to start an EHR,” Weinberg says.

Weinberg has experience configuring the EHR to reduce clicks at his practice, as well as others, in his work as an outside consultant. He says most practices are woefully inefficient when it comes to using the EHR, not realizing the built-in capabilities that allow for shortcuts.

Another small practice has also found success in modifying the EHR to make it more usable. James Legan, a primary-care physician at an eight-doctor practice in Great Falls, Mont., says he not only found an EHR system (North Kingstown, R.I.-based AmazingCharts) that best matched his work flow, but over time he has added capabilities to make it more intuitive. This has included electronic prescribing and patient portal applications, a cloud-based tool that integrates PDF and faxes from outside providers into the EHR, a way to project the patient’s record onto bigger screens in exam rooms, and a cloud-based server to automatically update treatment recommendations and medical information.

Both Weinberg and Legan have seen benefits from configuring their EHRs to make them more usable. Weinberg’s practice is a National Committee for Quality Assurance (NCQA) recognized Level 3 Patient-Centered Medical Home, thanks in large part to the EHR. Legan says a more usable EHR has led to better shared decision making between himself and his patients. “If the EHR is not usable, you are missing a huge opportunity. If you take energy away from having to worry about utilizing EHR, you can do other great things,” says Legan. “It’s easier to stay focused on the patient.”


Everyone agrees that it will be a shared effort — providers, vendors, government agencies, and other stakeholders — to make EHRs more usable out of the box. However, it may be more important for physicians to take a lead role, says the AMA’s Stack. “The government has to be more relaxed and step back, the vendors have to be more responsive to the doctors and other clinicians, and then the clinicians who use the tools have to accept that enhanced opportunity to [better EHRs] by offering areas for constructive improvement,” he says.

John Halamka, professor of medicine at Harvard Medical School and the chief information officer of the Beth Israel Deaconess Medical Center in Boston, agrees the government should take a step back. He says the heavy-handed, prescriptive approach of Meaningful Use may have been needed and appropriate at the start of EHR deployment, but is no longer viable in a value-based environment. “It’s up to the government to provide the incentives to pay for outcomes, and it’s up to providers and vendors working together to create optimal solutions to achieve these results. So I think going forward, the role of government should be reduced,” Halamka says.

Until the day comes where usability is no longer a ubiquitous issue, practices can heed the advice of Weinberg, Legan, and others who have achieved optimal utilization on their own. Stack advises physicians not to buy EHRs to comply with government regulations. Weinberg recommends hiring outside help that can come in with an unbiased eye and find areas where EHR use can be improved. “There is definitely ROI in doing this,” he says.

Legan advises physicians to “find the right tool for the job you are doing.” He adds, “Don’t view the EHR as something that can control you. Figure out what that EHR can do for you and make it happen. If it can’t do it, find one that can.”

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