EHR usability Gap - Specified Context of Use

The efficient and effective use of Electronic Health Records are essential, as these systems are increasingly becoming a central tool for patient care.

The Health Information Technology for Economic and Clinical Health (HITECH) Act provided providers with a significant financial incentive to increase the adoption and use of EHRs. EHR vendors were required to conduct and report on a summative usability evaluation of their system as part of the Stage 2 Meaningful Use--now known as the "Promoting Interoperability" program (The ONC 2014 Edition Certification, and the 2015 Edition Certification). However, a recent report funded by the Agency for Healthcare Research and Quality (AHRQ), identified several “issues” with the certified EHR vendors in the processes, practices and use of standards and best practices with regard to usability and human factors.

These “issues” discussed in the AHRQ report centered around EHR vendor usability processes and practices during the different phases of product development and deployment as a key research gap.

In order to secure the full MACRA and MIPS payments for their clients, EHR vendors will need re-evaluate the usability of their solution(s). The ONC 2015 edition Safety-enhanced Design criteria of the ONC certification (§170.315.g.3) raised the usability and user experience bar in an attempt to improve the processes that EHR vendors are required to follow. The 2015 Edition also increases the quality and size of the summative evaluations that are conducted and reported. The results of these studies will again be presented on the ONC’s Certified Health IT Product List (CHPL), but this time along with the actual raw data obtained during the study.

According to recent reports, medical mistakes are now the 3rd largest cause of death. We all can imagine a situation where the lack of usability of a Health IT vendor product can become a patient safety issue. The usability of health IT system, however, is more than the responsibility of just the EHR vendor.

Health IT is a critical tool that needs to be examined in its entire context of use. Vendors, and providers and implementers need to take a more holistic approach in examining all of the human “touch points” with the entire system and work hard to create systems that help reduce errors and save lives.

We’ve identified several of these “touch points” that are not clearly addressed in the ONC certification program, and provide some thoughts below on how we think they should be addressed.

Manual Data entry

What happens with a medical group is moving to an EHR from paper records? Most EHRs are designed for using current data, but very little has been done with the manual data entry of paper records into EHRs. The initial entry of data is a completely different user journey and, as such, requires a different set of User Interfaces. We call this the “add/edit problem” and it has been around in enterprise systems for many, many years. See our thought leadership on the add/edit problem at

Usability during implementation

We think that the biggest potential gap in the usability of EHRs takes place during the actual implementation of the EHR in the clinical setting. There are so many individual settings or clinical defaults that can be adjusted/configured to best match the actual working medical environment that the specific EHR is being used. Configuration of the "unit of measure" is one of the most talked about examples of this is the issue and is highlighted in the Joint Commissions Sentinel Alert 54.

If an EHR is requiring the medical staff to enter their patient’s weight using the metric system, but all of the scales in the office are using the US/English system of measure, the EHR system needs to be reconfigured. The medical staff needs to be able to enter the US weight directly – instead of requiring the over worked nurses and other staff to manually multiply their patients reading by 2.2 in order to convert it to kg.


A big gap in the usability of many current EHR systems is that they are not designed to match clinical workflow. In fact most are designed predominantly for billing.

See ZdoggMD's “EHR state of mind” Zubin raps “EHR, It’s just a glorified billing platform with some patient stuff tacked on”

Systems should be designed to match the workflow that is used in the clinical setting, and allow that workflow to be modified when there are changes to the clinical workflow. Matching the clinical workflow will reduce the cognitive load that is placed upon the medical staff because the system will adjust/adapt to their needs, instead of forcing clinicians to adapt to the processes that are hard coded into the system. See Jean Piaget and the Usability of health IT

Matching mental models

There is a considerable amount of research that describes the differences between Novice and Expert users in the way that they approach problems. Most systems are designed for novice users, some for expert users, but the majority of actual users actually fall into what has been called by Alan Cooper the “Perpetual Intermediate” group. EHR vendors need to better understand who and how their systems are being used, see Aim for the middle


Another HUGE gap that EHR’s can help to fill is the communication gap that exists between doctor and patient, between doctors and between patients/caregivers and other patients. What is really needed is an Enterprise Social Network (ESN) that is HIPPA compliant that allows effective communication between doctors- for collaboration on treatments; communication between Dr.’s and their patients (patient portals are, shall we say – weak at best”) and communication between patients.


For most EHRs and other HealthIT , Pharmacists seem to be pretty much out of the loop, yet they have an expertise that can and should be shared with the patient. There has to be a way to get their expertise into the system. Patients need to feel more comfortable asking them for advise, or Pharmacists need to become much more active in their participation in healthcare. If a new medicine is prescribed, patients need to ask their pharmacist if this medicine will interfere with any of their lifestyle or particular diet. What effect does drinking alcohol have of its effectiveness? A proactive pharmacist can save a live too!

We will continue to encourage HealthIT (and other software) vendors to see the “Big Picture” of usability.

We will continue to encourage EHR vendors to take a more holistic quality approach when designing and evaluating the usability and user experience of their HealthIT and mHealth apps. In fact, the ISO usability definition seems to be quite appropriate to this discussion: “Usability is the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency and satisfaction in a specified context of use” (ISO 9241-11, 1998).

Let’s not forget about the “specified context of use.”