Usability should become part of the certification test for electronic health records to ensure systems are designed so clinicians not only find them appealing to use but operate them safely and effectively.

That was one of the recommendations made by researchers in a report about assessing and improving the usability of electronic health record systems prepared for the Agency for Healthcare Research and Quality (AHRQ).

Usability, which implies both ease-of-use and designing for effective use, will be critical to driving broad adoption of electronic health records (EHRs), according to the report. Without serious attention being paid to these factors, healthcare providers sometimes find flaws once they have deployed a system, forcing them to make costly workarounds or returns.

Providers' experiences with key EHR design, such as the display of menu listings, the use of pop-up boxes and the links between screens, is a big factor in determining the usefulness of an EHR, according to the May 27 AHRQ report.

Usability issues are usually not simple, one-function problems, but tend to be pervasive throughout the EHR, according to the report. While small-scale flaws are often reported and corrected after deployment, those issues may not determine a product's usability.

"By not identifying critical usability issues through a wide range of user testing during design and development, vendors are opening the door to potential patient safety incidents and costly post-release fixes," the report said.

AHRQ hired two research organizations, James Bell Associates and the Altarum Institute, to evaluate how vendors integrate usability in their products. They interviewed vendors, including Cerner Corp. and athenahealth and also the Veterans Health Administration.

Later this month, AHRQ plans to award a follow-on project for the development, testing and distribution of a toolkit that healthcare organizations can use to evaluate their EHR systems' usability, accessibility and information design.

AHRQ is working closely with the National Institute of Standards and Technology (NIST) and the Office of the National Coordinator (ONC) to follow through on the recommendations in its report.

Among the AHRQ report findings, specific best practices and standards of design, testing and monitoring usability of EHRs are not readily available.

"There are no standards most of the time, and when there are standards, there is no enforcement of them," the report said. The software industry has plenty of guidelines and best practices, "but in health IT, there are none," the report said.

Vendors reported that they use proprietary industry guidelines and general software to develop usability.

Many vendors also did not initially handle the potential negative impact of their products as a design priority. Instead, they had a variety of formal and informal processes for identifying, tracking and tackling patient safety issues that related to the usability of their EHRs.

Vendors reported that they collect lists of incidents related to usability as a subset of user-reported "bugs" and product-enhancement requests.

Vendors generally supported a recommendation that an independent body guide development of usability standards for EHRs. "Because vendors view usability as their chief competitive differentiator, collaboration among vendors with regard to usability is almost nonexistent," the report said.

Among other recommendations, the researchers said that vendors need to adhere to formal user-design methods and to test their EHR designs throughout the product lifecycle with more diverse groups of customers than computer savvy individuals.

The report is online .