Usability of EHRs remains a priority for ONC

HealthIT Buzz

Excerpts from HealthIT Buzz Blog post by Jacob Reider, MD / Acting National Coordinator for Health Information Technology

Early adopters of technology are well known to tolerate imperfections. Traditional market forces generally keep products that are difficult to use from succeeding, and as any user of an Apple Newton External Links Disclaimer remembers, the promise of an innovative solution isn’t always realized and will/should fail in the marketplace. Yet some have argued that the meaningful use incentive program altered market forces in a way that prevents well-intentioned products from failing as did Apple’s first “personal digital assistant.” Health IT is not the same as consumer electronics:

a) The user isn’t always the buyer. This causes usability to be a less significant component of buying decisions.

b) Multi-year contracts and technical “lock-in” cause portability to be a true challenge. One can’t just walk away from an EHR that’s not performing as expected. Buying an EHR is more like buying an airplane than a clock radio.

c) Legacy software in a high-risk environment will evolve slowly – for good reason. One can’t change workflow or user experience too quickly, as changes in the user interface can increase error rates even if the new design is better for new users. Errors can harm or kill people. Developers need to evolve user experience slowly and carefully. Usability won’t improve overnight.

d) Health IT systems are complex and require local configuration. Inadequate local resources can cause well-designed products to offer terrible user experiences. To the end-user, they have no way of knowing who is responsible – the IT department or the software developer? Was it Boeing or United Airlines who made these seats so uncomfortable?

Do “I know it when I see it?“ or is there something more complex about enhancing/defining/recognizing usability in Health IT? How does the usability of HIT products have an impact of the quality and efficiency of care delivery? How can we help make HIT products more usable? What is usability?

The (ISO) definition of usability, referenced in the 2009 HIMSS usability primer is a good start:

“Usability is the effectiveness, efficiency and satisfaction with which specific users can achieve a specific set of tasks in a particular environment. In essence, a system with good usability is easy to use and effective. It is intuitive, forgiving of mistakes and allows one to perform necessary tasks quickly, efficiently and with a minimum of mental effort. Tasks which can be performed by the software (such as data retrieval, organization, summary, cross‐checking, calculating, etc.) are done in the background, improving accuracy and freeing up the user’s cognitive resources for other tasks.”


We know that no software is perfect, and therefore no EHR is perfect. Like the airplane cockpit, the EHR is a complex instrument, to be used by highly trained professionals to perform complex tasks. Any errors in execution of these tasks could be deadly.


Working with our partners at NIST, we have hosted three annual conferences on usability over the course of the past three years, where we gathered industry experts, health IT developers, provider and patient advocates, and representatives of other federal agencies to learn from each other and provide guidance to the ONC. Artifacts from these meetings are available.

ONC’s HIT Policy Committee has hosted two hearings on EHR usability.

ONC commissioned the IOM’s report on Health IT and Patient Safety, which includes several recommendations for how health IT usability is an important part of safer care delivery.

ONC’s 2014 Standard and Certification Criteria include two requirements in the domain of quality management, and usability and safety.

ONC has funded the work at UT Houston under the SHARP C project to develop:

Tools External Links Disclaimer for usability evaluation
Guidance for HIT developers as they begin to incorporate usability into their development lifecycle for how health IT developers might make complex tasks like medication reconciliation easier and more accurate.

What’s next?

Enlightened providers like family physician Jeff Belden and “passionate design expert” Stephen Anderson help us think critically about how we develop health IT systems, and question assumptions about the best path forward. As Steve Jobs once said, “it’s not the customer’s job [to figure out how to best design a system].” Belden reminds us that we need to carefully consider the clinician’s native workflow in the optimal design of an EHR process. Anderson’s complex model reminds us that usability is just a milestone along the continuum from functional to meaningful design.

We are working hard to both understand these issues and define an appropriate balance for the government’s role in helping evolve health IT toward better efficiency and safety through enhanced usability. What do you think?

See the full article at

The Usability People work with you on improving the Usability of Healthcare IT.

The Usability People
Together we may save a life! #SafeHealthIT