The promise of improved health care efficiency, quality and safety that electronic health records (EHRs) were supposed to bring has not yet been fully realized. Too often, EHRs bring difficulties in use, delays in completing tasks and increasing frustration for the physicians who use them.
Part of the problem is that EHR-vendor contracts often contain clauses that serve to stymie physicians’ efforts to improve the usability and safety of the systems they work in, according to a JAMA Viewpoint essay, “Improving Electronic Health Record Usability and Safety Requires Transparency.”
“EHR usability, which is the extent to which this technology can be used efficiently, effectively and safely by clinicians to deliver care, has emerged as one of the most pressing issues in health care,” says the essay, co-written by AMA Chief Medical Information Officer Michael Hodgkins, MD; Raj Ratwani, PhD, director of Medstar Health’s National Center for Human Factors in Healthcare; and David W. Bates, MD, chief of general internal medicine at Brigham and Women’s Hospital.
“The inability to address the issues of usability represents a market failure,” they added.
Contracts may contain “gag clauses” requiring vendor authorization for clinicians to share data on problems they identify, they wrote.
Congress identified the problem and addressed it in the 21st Century Cures Act, passed in 2016. The wide-ranging law contains provisions that bar EHR vendors from prohibiting or restricting communication relating to the usability of EHRs. But the Office of the National Coordinator for Health IT (ONC) is still developing definitions regarding what constitutes a prohibition or restriction.
The authors outlined three specific problems stemming from “information blocking” created by vendors’ lack of transparency or EHR users’ inability to freely communicate about usability issues. They outlined the criteria the ONC should consider as it works to define information blocking.
Dr. Hodgkins and his colleagues wrote that EHR information blocking can harm patient care in these three ways.
Prevents usability and safety research from being conducted. Identifying usability and safety challenges requires using simulated clinical scenarios and test cases, but EHRs may lack the functionality for testing and research. National policies should require EHRs to have the ability to enter test cases.
“The inability to share critical usability and safety information can affect product improvement and patient-safety initiatives,” Dr. Hodgkins and his colleagues wrote. “Without transparency and independent assessments of product usability, purchasers cannot make informed decisions, and EHR vendors have less incentive to compete on usability.”
Prevents participation in usability and safety research. EHR vendors and physicians have an asymmetrical relationship with clinicians reliant on companies for technical support and system upgrades. This is especially true for small medical practices.
Health care organizations may avoid participating in research or sharing information so they can keep a positive relationship with their vendor. The authors wrote that national policy prohibiting vendors from taking “adverse actions” against clinicians participating in usability and safety research should be adopted.
Prevents sharing of usability and safety information. Many contracts prohibit sharing visual representations of EHRs—such as screenshots, videos or mock-ups—that closely resemble the products. This prevents their use in journal articles, presentations, comparison reports and even safety alerts.
Physicians are often the first people to identify patient safety threats. Discussing issues among their peers, recommending practical solutions and enlisting transparency to improve product safety is critical. There should be policy requiring that vendors give timely permission to release safety and usability information.
Patient safety and physician satisfaction can be improved by policies encouraging identification of problems and dissemination of usability and safety information. Everyone would benefit from such policies, the authors wrote, because they will lead to improved care and easier-to-use technology.
