Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA

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This is a review of Middleton's 2013 paper, Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. [1]


In recent years, the United States (US) has launched a far-reaching initiative to implement electronic health records (EHR) throughout the healthcare system. The fundamental goals of this initiative are to improve patient safety and decrease costs. As these systems are being implemented, more attention is being paid to the unintended consequences and the potential for harm. In 2012, the American Medical Informatics Association (AMIA) convened a task force with subcommittees to investigate the current state of the industry with respect to usability, productivity, and patient safety. Activities included literature searches, review of studies in progress within US federal agencies and federally funded projects, and evaluation of lessons learned in other high-tech, high-risk industries such as aviation. This article reported AMIA’s principle findings and recommendations. [1]

Framework of Study

The task force’s framework included three concepts:

The task force concludes that optimal use of an EHR results from the integration of “application design, usability, human factors engineering, implementation, training, monitoring, and feedback”. Usability has been identified as one of the major factors affecting clinicians’ successful use of an EHR, including errors and the risk of adverse events. Sittig and Singh assert that EHR errors occur “anytime health IT is unavailable for use, malfunctions during use, is used incorrectly by someone, or when health IT interacts with another system component incorrectly, resulting in data being lost or incorrectly entered, displayed, or transmitted”.

An example under each of those three categories would be in order:

Safe and effective use of EHR - At Point of Care (POC), that is at the time of an encounter, an alert (using Analytics), that tells the care giver that the patient has recently had a heart attack and was admitted to the Hospital but is still not put on beta blockers.

EHR Usability-associated medical errors - Again at POC, as a prescription is being written for the diabetes patient, an alert pops up to say that the patient has been diagnosed with pancreatitis and so can't be prescribed medication that performs DPP-4 functions (e.g. Onglyza) as these could potentially increase the risk.

EHR usability - Again, at POC, the values primed from the patient's previous visit asks for reconfirmation if not edited / changed. This storing of values from the patient's previous session is typically done to reduce data entry errors but could become an issue if the doctor overlooks the display - as an example, if the doctor wants to reduce the strength of a certain medication as it is not working as intended but doesn't notice the medication strength showing on the screen, could write another prescription for the same strength, causing potential problems. [2]

Usability Recommendations

To address usability, AMIA’s recommendations build on three objectives: usability principles, use cases, and interface guidelines.

Usability Principles

First, usability concepts are referenced, including nine from the Healthcare Information Management and Systems Society (HIMSS) as well as additional factors described by Zhang and Walji of the National Center for Cognitive Informatics and Decision Making in Healthcare. These principles include the following:

  • Design consistency
  • Visibility of system state
  • Real-world match
  • Minimalism/simplicity
  • Efficiency
  • Minimization of cognitive load
  • User feedback
  • Flexibility/user control
  • Definitive closure
  • Reversibility/forgiveness
  • Utilization of user language
  • Effective presentation of information
  • Availability of help

Use Cases

Secondly, AMIA recommends the development of eight standardized use cases to be used by EHR developers and certification bodies. These use cases emphasize EHR tasks that are most prone to causing patient harm including CPOE, clinical information reconciliation, as well as tasks involving medication prescribing, administration, allergies, contraindications, and drug-drug interactions.

Interface Guidelines

The third leg of AMIA’s usability recommendations includes the development of standard user interface guidelines, particularly for tasks that involve a high risk for patient harm. These standards would address features such as color, controls, layout, and application flow.


AMIA recognizes the obstacles to implementing these recommendations, especially in the area of usability testing and evaluation. Challenges arise due to the complex socio-technical systems that involve software, organizational culture, and multiple users in various working environments separated by space and time. The authors suggest that much can be learned and emulated by studying the successes of the aviation industry which also grapples with high-risk situations and complex decision-making.

Challenge on usability testing and functionality evaluation is a well-documented issue. Segall et all (2011), reported that previous evaluation have been done on the final product of a system. However, this proves to be costly. Even so, it is on PHR Segall et al evaluated usability using Human-Center Design Method. Some of the benefits of using this method are the following:

•It is designed to expose system’s effect on users cognitive task

•Since the evaluation method is user centered, it gives an opportunity for potential users to design the final product in a way that improves overall usability of the system

•The fact that the evaluation is done while the system is under development saves so much cost compare to an evaluation that is done on the final product.Implementing such methods on EMR evaluation will reduce some of the challenges at hand.


In summary, AMIA makes several recommendations targeted to specific stakeholders including vendors, the Office of the National Coordinator, National Institute of Standards and Technology, and the Agency for Healthcare Research and Quality. These recommendations include developing standardized methods and use cases for usability testing, promoting best practices, establishing a voluntary adverse event reporting process, developing an educational campaign on the safe and effective use of EHRs, developing a style guide for user interface design, performing usability testing on critical EHR functions, adopting system implementation best practices, and finally monitoring and reporting IT-related adverse events. AMIA aims to encourage ongoing dialogues and foster increased understanding of the effect of usability on patient safety and quality care, and promote wider coordination of activities that are currently underway as well as urge more to come.


  1. 1.0 1.1 Middleton, B., Bloomrosen, M., Dente, M. A., Hashmat, B., Koppel, R., Overhage, J. M., … Zhang, J. (2013). Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. Journal of the American Medical Informatics Association : JAMIA, 20(e1), e2–e8. doi:10.1136/amiajnl-2012-001458 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3715367/
  2. Impact of Electronic Health Record Systems on Information Integrity: Quality and Safety Implications.http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pmc/articles/PMC3797550/

Segall, N, Saville, J, Engle, P, Carlson, B, Wright, M, Schulman, K, Tcheng, J. (2011). Usability Evaluation of a Personal Health Record. AMIA, 2011, 1233-1242. http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pmc/articles/PMC3243224/