Physicians score EHRs an F on usability, study finds

Electronic health record systems score in the bottom 9th percentile of technologies when evaluated for usability, according to a recent study published in the journal Mayo Clinic Proceedings.

That's a problem, because physicians who rate their EHR experience poorly are more likely to report symptoms of burnout, study authors wrote.

"If an interface isn't designed thoughtfully and carefully for a user's needs, it can add to the cognitive load of completing a task," said Dr. Ted Melnick, the study's lead author and assistant professor of emergency medicine at Yale School of Medicine. His previous research has looked at developing and testing systems for the emergency department, applying user-centered design principles.

In the study, EHRs earned an average score of 45 on the system usability scale, a standard metric used to measure technology usability on a scale of 0 to 100. The scale, which is already used widely in industries outside of healthcare, asks users to respond to 10 prompts to assess their view of how efficient or complex a system—in this case, EHRs—is to use.

Researchers invited a random sample of 1,250 physicians from the American Medical Association's physician master file to respond to a system usability scale questionnaire on EHRs in late 2017 and early 2018; 870 of whom completed the survey.

When benchmarking EHRs' score of 45 across previous research on other technologies, the researchers found EHRs fell in the bottom 9th percentile—earning a grade of F.

That suggests that EHRs "as currently designed, implemented and regulated, lack usability as a necessary feature, resulting in EHRs that are extremely hard to use compared to other common technologies," AMA President Dr. Patrice Harris said in a statement. The AMA was a collaborator on the study.

Other technologies that EHRs were benchmarked against included Google's search function, which scored a 93, and microwaves, which scored an 87, according to previous research employing the system usability scale. That earned Google searches and microwaves grades of A and B, respectively.

Microsoft's Excel received a score of 57, which while higher than EHRs, also put it in the F range.

"It might not be realistic to say we can boil down an EHR to something as simple as a Google search," Melnick noted. There's a "trade-off between complexity and usability."

Researchers further linked physicians' view of EHR usability with their odds of burnout, based on the Maslach Burnout Inventory, which assesses symptoms like emotional exhaustion and feelings of accomplishment. A physician's odds of reporting symptoms of burnout dropped 3% for each point they more favorably evaluated their view of EHR usability, the study found.

While that doesn't prove that poor EHR usability causes burnout, it does "help bolster the case" that it's a contributor, said Dr. Paul Dexter, a research scientist at the Regenstrief Institute who was not affiliated with the study. "I'm not surprised by the results," he said. "It's consistent with the previous literature."

"I don't take too completely seriously a grade of an F," he added. "It seems a little excessive, in terms of clinicians are able to do their job on a daily basis. It's just not as efficient—and perhaps with less support—than would be hoped."

Physicians have consistently expressed frustration with the amount of time they spend using EHRs. A 2018 study in the journal Family Medicine found that primary-care physicians actually spend more time in the EHR than on face-to-face time with patients, with the majority of physicians completing documentation in the EHR after hours.

However, while the system usability scale is meant to quantify usability of the EHR system itself, study authors acknowledged that physicians may conflate their view of EHR software with other burdens associated with technology, such as documentation requirements.

That would reflect much of the feedback HHS' Office of the National Coordinator for Health Information Technology has been hearing from clinicians, said Dr. Thomas Mason, the agency's chief medical officer. The ONC has hosted listening sessions with clinicians to discuss EHR administrative burdens, resulting in a draft strategy it released with the CMS to tackle the issue in November 2018.

The ONC is aiming to have the final version of the strategy issued before the end of the year.

"One of the things that we heard, loud and clear, is that the usability needs to be improved," Mason said. But documentation related to billing and regulatory requirements were overall the No. 1 issue clinicians shared, he said. He noted the new Medicare physician-fee schedule from the CMS may provide some relief, as it requires documentation of patient histories and exams only as medically appropriate for office and outpatient evaluation and management visits.

Melnick said that while benchmarking EHRs against other technologies was a first step for assessing their usability, the system usability scale could continue to be applied to specific tasks within the systems to help the industry get a clearer picture of which components of EHRs are driving frustration among physicians.

"We could start to track these gaps, and close the gaps, in terms of usability," Melnick said.