AMA Calls for Design Overhaul of Electronic Health Records to Improve Usability

Press Release | American Medical Association | September 16, 2014

Champions reboot of technology to help physicians take better care of patients

CHICAGO - Sept. 16, 2014 - Building on its landmark study with RAND Corp. confirming that discontent with electronic health records (EHRs) is taking a significant toll on physicians, the American Medical Association (AMA) today called for solutions to EHR systems that have neglected usability as a necessary feature. Responding to the urgent physician need for better designed EHR systems, the AMA today released a new framework outlining eight priorities for improving EHR usability to benefit caregivers and patients.

"Physician experiences documented by the AMA and RAND demonstrate that most electronic health record systems fail to support efficient and effective clinical work," said AMA President-elect Steven J. Stack, M.D. "This has resulted in physicians feeling increasingly demoralized by technology that interferes with their ability to provide first-rate medical care to their patients."

While AMA/RAND findings show physicians generally expressed no desire to return to paper record keeping, physicians are justly concerned that cumbersome EHR technology requires too much time-consuming data entry, leaving less time for patients. Numerous other studies support these findings, including a recent survey by International Data Corporation that found 58 percent of ambulatory physicians were not satisfied with their EHR technology, "most office-based providers find themselves at lower productivity levels than before the implementation of their EHR" and that "workflow, usability, productivity, and vendor quality issues continue to drive dissatisfaction."

"Now is the time to recognize that requiring electronic health records to be all things to all people - regulators, payers, auditors and lawyers - diminishes the ability of the technology to perform the most critical function - helping physicians care for their patients," said Dr. Stack. "Physicians believe it is a national imperative to reframe policy around the desired future capabilities of this technology and emphasize clinical care improvements as the primary focus."

To leverage the power of EHRs for enhancing patient care, improving productivity, and reducing administrative costs, the AMA framework outlines the following usability priorities along with related challenges:

  • Enhance Physicians' Ability to Provide High-Quality Patient Care
  • Support Team-Based Care
  • Promote Care Coordination
  • Offer Product Modularity and Configurability
  • Reduce Cognitive Workload
  • Promote Data Liquidity
  • Facilitate Digital and Mobile Patient Engagement
  • Expedite User Input into Product Design and Post-Implementation Feedback

These priorities were developed with the support of an external advisory committee comprised of practicing physicians, as well as noted experts, researchers and executives in the field of health information technology.

Despite numerous usability issues, physicians are mandated to use certified EHR technology to participate in the federal government's EHR incentive programs. Unfortunately, the very incentives intended to drive widespread EHR adoption have exacerbated and, in some instances, directly caused usability issues. The AMA has called for the federal government to acknowledge the challenges physicians face and abandon the all-or-nothing approach for meeting meaningful use standards. Moreover, federal certification criteria for EHRs need to allow vendors to better focus on the clinical needs of their physician customers.

The AMA recognizes that not all EHR usability issues are directly related to software design itself. Some issues are a result of institutional policies, regulations, and sub-optimal implementation and training. The AMA will continue to move aggressively on these fronts, including empowering physicians to work with vendors and other to develop and implement more usable products.

To advance these goals, the AMA plans to utilize the eight usability priorities to lead EHR improvements for physicians, vendors, federal and state policymakers, institutions and health care systems and researchers, which could ultimately lead to greater professional satisfaction for physicians. Through these efforts, the AMA hopes to advance the delivery of high-quality and affordable health care to improve the health of the nation.

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Editor's Note:  The following selection of quotes has been drawn from the AMA/RAND research report and members of the AMA's external advisory committee on EHR usability.

AMA/RAND Research Report
Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy

"Electronic health record usability, however, represents a unique and vexing challenge to physician professional satisfaction. Few other service industries are exposed to universal and substantial incentives to adopt such a specific, highly regulated form of technology, one that our findings suggest has not yet matured."

Gary Botstein, M.D.
AMA Advisory Committee on EHR Physician Usability
Decatur, Georgia

"The ultimate measure of a well-designed electronic health record is how it helps physicians take better care of patients. It is critical that enhancing quality patient care is the first priority of an electronic health record and data collection is second. Particularly for physicians in solo and small practices, digital data collection has become overwhelming and interferes with and detracts from time with patients."

John Mattison, M.D.
AMA Advisory Committee on EHR Physician Usability
Southern California

"Data liquidity is critical to optimal patient safety and quality outcomes, especially as it supports a complete health record, and is essential for safe transitions between different care providers."

Christine Sinsky, MD
AMA Advisory Committee on EHR Physician Usability
Dubuque, Iowa

"The designs of many electronic health records do not meet the needs of physicians and too often detract from valuable time with patients. As a practicing physician, my desire is that EHRs will help me focus on patient care.  They can do this by providing concise, context sensitive and real time data that is uncluttered by extraneous information. This will help in eliminating the current information overload and unnecessary administrative data entry that is overwhelming today's physicians and interfering with patient care."

Steven Steinhubl, MD
AMA Advisory Committee on EHR Physician Usability
La Jolla, California

"Given the rapid growth of digital technology in health care, whether for health and wellness, or the management of chronic illness, a comprehensive health information technology strategy must include interoperability between a patient's mobile technology, telehealth technology, and the electronic health record."

Raj Ratwani, PhD
AMA Advisory Committee on EHR Physician Usability
Washington, DC

"User-Centered Design (UCD) is critical to advancing electronic health record usability to meet the cognitive and workflow needs of physicians.  While some electronic health record vendors have implemented UCD, their results have been inconsistent and many others do not utilize UCD."

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Media Contact:
Robert J. Mills
AMA Media & Editorial
(312) 464-5970
[email protected]

Open Health News' Take: 

Well, it looks like the American Medical Association (AMA) has finally taken a stand on the dreadful state of usability on the part of proprietary EHR. Two issues.

First, while their proposals would have been commendable years ago, they still do not address the fundamental problem which is the proprietary EHR business model. This issue has been addressed by Dr. Bruce Wilder in several places for years, including this article: The Politics of the EHR: Why we’re not where we want to be and what we need to do to get there. This is also a recurring theme that Open Health News has been raising since its inception.

The AMA is still protecting the proprietary EHR vendors and their lock-in business model. Nowhere in their press release, or the summary of their framework, or the framework document itself, does it mention open source. Then instead of using the correct term for data interoperability and exchange, which is "open data," the AMA uses the term "data liquidity." That term was invented by proprietary EHR vendors so they could avoid opening up their applications, which is the key to a any EHR interoperablity solutions.

The next point that the AMA misses is the fact that VistA already does everything that their framework calls for. The clear solution, as detailed by Dr. Wilder, is for hospitals to simply adopt VistA and stop wasting hundreds of billions of dollars on lousy proprietary EHRs. As a recent survey by Medscape documents, physicians rank VistA CPRS as the #1 EHR in basically every single category, including usability. This is detailed in an article by Edmund Billings titled Physicians Prefer VistA-So Should Decision Makers.

The last point is that the AMA is very late with their framework. The National Nurses United (NNU) organization, the largest organization of nurses in the United States, has been warning about dangerous EHRs for years, going so far as to stage demonstrations and strikes against hospitals implementing lousy EHRs. AMA needs to acknowledge the role of the NNU and address in greater detail their patient safety concerns.

Below are just a few of the press releases issued by the NNU which more accurately describe the patient safety issues posed by proprietary EHRs.

RNs Urge Tougher Federal Oversight On Unproven Medical Technology On which Hospitals Spend Billions
Press Release | National Nurses United | July 8, 2014
National Nurses United is calling on the U.S. Food and Drug Administration to enact meaningful oversight and public protections on the use of unproven medical technology that is rapidly spreading through the nation’s healthcare system. NNU, the largest U.S. organization of nurses, made its appeal in formal comments submitted Monday to the FDA which has just concluded a comment period on its proposed “Risk-Based Regulatory Framework and Strategy for Health Information Technology Report.”

Nurses Launch New Campaign To Alert Public To Dangers Of Medical Technology And More
Press Release | National Nurses United | May 13, 2014
Sweeping changes underway in the nation’s health care delivery system that expose hundreds of thousands of patients to severe risk of harm are the focus of a major new national campaign by the nation’s largest organization of nurses announced today. An unchecked proliferation of unproven medical technology and sharp erosion of care standards are rapidly spreading through the health care system, far outside the media spotlight but frighteningly apparent to nurses and patients, says National Nurses United. In response, NNU has launched a major campaign featuring radio ads from coast to coast, video, social media, legislation, rallies, and a call to the public to act, with a simple theme – “when it matters most, insist on a registered nurse.”  The ads were created by North Woods Advertising and produced by Fortaleza Films/Los Angeles.  Additional background can be found at

Nurses Warn Epic EHR Causes Serious Disruptions to Safe Patient Care at East Bay Hospitals
Press Release | California Nurses Association | July 11, 2013
Introduction of a new electronic medical records system at Sutter corporation East Bay hospitals has produced multiple problems with safe care delivery that has put patients at risk, charged the California Nurses Association today...In over 100 reports submitted by RNs at Alta Bates Summit Medical Center facilities in Berkeley and Oakland, nurses cited a variety of serious problems with the new system, known as Epic. The reports are in union forms RNs submit to management documenting assignments they believe to be unsafe.

Affinity RNs Call For Halt To Flawed Electronic Medical Records System Scheduled To Go Live Friday
Press Release | National Nurses United | June 18, 2013
Affinity Medical Center RNs in Massillon, Ohio are calling on hospital officials to delay the planned June 21 implementation of the Cerner electronic medical records (EMR) system, until the hospital bargains with the nurses and proceeds in a safe manner. The direct-care RNs, represented by the National Nurses Organizing Committee (NNOC) in Ohio, an affiliate of National Nurses United (NNU), say that nurses, the primary users of the complex system, have had insufficient training, which will put patients at risk. The implementation, which has been done without bargaining with NNOC, reflects yet another violation of federal labor law by Affinity, nurses say. Nurses have documented their concerns in a detailed letter to hospital officials. Those concerns include woefully inadequate training, short staffing in the first days of the roll out, and the subsequent risk of harm to their patients.  The system, they say, has the potential of violating the Ohio Nursing Practice Act because it doesn’t permit RNs to communicate individualized, potentially life-saving information about their patients.

Last but not least, the AMA also does not explicitly address the serious patient safety issues raised for years now by Dr. Scot Silverstein in his blog Healthcare Renewal.

Roger A. Maduro, Publisher and Editor-in-Chief, Open Health News.