An Exploration of Barriers, Facilitators, and Suggestions for Improving Electronic Health Record Inbox-Related Usability: A Qualitative Analysis | Electronic Health Records | JAMA Network Open | JAMA Network
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    1 Comment for this article
    EHRs CAN be improved
    Frederick Rivara, MD, MPH | University of Washington
    We all know that the EHR is cited as the leading factor in physician burnout. This study shows that there are design changes that can be made to improve the usability of EHRs and make it more efficient for the users and reduce the stress of its use. It would seem to me that hospitals which are investing hundreds of millions in their EHR would want to help reduce burnout of their docs.
    CONFLICT OF INTEREST: Editor in Chief, JAMA Network Open
    Original Investigation
    Health Informatics
    October 4, 2019

    An Exploration of Barriers, Facilitators, and Suggestions for Improving Electronic Health Record Inbox-Related Usability: A Qualitative Analysis

    Author Affiliations
    • 1Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
    • 2Department of Medicine, Baylor College of Medicine, Houston, Texas
    • 3School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston
    • 4Center for Healthcare Quality and Safety, University of Texas Health Science Center at Houston, Houston
    JAMA Netw Open. 2019;2(10):e1912638. doi:10.1001/jamanetworkopen.2019.12638
    Key Points español 中文 (chinese)

    Question  What factors are associated with physicians’ situational awareness and efficiency of processing messages delivered via electronic health record (EHR) inboxes?

    Findings  This qualitative analysis included interviews with 25 physicians in 6 health care organizations and identified 60 barriers and 32 facilitators associated with EHR inbox designs and workflows and 28 unique suggestions for improvement. Physicians suggested EHR developers and health care organizations reduce message processing complexity, simplify interface design, provide features to reduce physician cognitive load, facilitate care team communication, and streamline inbox message content.

    Meaning  This study’s findings included multifaceted recommendations associated with improving EHR inbox usability and workflow to improve safety and efficiency and reduce physician burnout.


    Importance  Managing messages in the electronic health record (EHR) inbox consumes substantial amounts of physician time. Certain factors associated with inbox management, such as poor usability and excessive and unnecessary inbox messages, have been associated with physician burnout. Additionally, inbox design, usability, and workflows are associated with physicians’ situational awareness (ie, perception, comprehension, and projection of clinical status) and efficiency of processing EHR inbox messages. Understanding factors associated with inbox usability could improve future EHR inbox designs and workflows, thus reducing risk of burnout while improving patient safety.

    Objective  To determine barriers, facilitators, and suggestions associated with EHR inbox-related usability.

    Design, Setting, and Participants  This qualitative study included cognitive walkthroughs of EHR inbox management with 25 physicians (17 primary care physicians and 8 specialists) at 6 large health care organizations using 4 different EHR systems between May 6, 2015, and September 19, 2016. While processing EHR inbox messages, participants identified facilitators and barriers associated with EHR inbox situational awareness and processing efficiency and potential interventions to address such barriers. A qualitative analysis was performed on transcribed recordings using an inductive thematic approach with an 8-dimension sociotechnical model as a theoretical lens from May 6, 2015, to August 15, 2019.

    Results  The cognitive walkthroughs identified 60 barriers, 32 facilitators, and 28 suggestions for improving the EHR inbox. Emergent data fit within 5 major themes: message processing complexity, inbox interface design, cognitive load, team communication, and inbox message content. Within these themes, similar barriers were identified across sites, such as poor usability due the high numbers of clicks needed to accomplish actions. In certain instances, an identified facilitator at one site provided the exact solution needed to address a barrier identified at another site.

    Conclusions and Relevance  This qualitative study found that usability of the EHR inbox is often suboptimal and variable across sites, suggesting lack of shared best practices related to information management. Implementation of optimized design features and workflows will require EHR developers and health care organizations to collectively share this responsibility. Development of regional or national consortia to support collaborative sharing and implementation of EHR system best practices across EHR developers and health care organizations could also improve safety and efficiency and reduce physician burnout.