OBJECTIVE: To determine whether the Office of the National Coordinator's policy change restricting the use of "gag clauses" in contracts between electronic health record (EHR) vendors and healthcare facilities increased the prevalence of screenshots in peer-reviewed literature. MATERIALS AND METHODS: We reviewed EHR usability and safety-related peer-reviewed journal articles from 2015 to 2023 and quantified the number of articles containing screenshots. For those that did not contain screenshots, we identified whether they would have benefited from screenshots. RESULTS: When gag clauses were permitted 6 of 79 (7.6%) of articles contained screenshots and 8 (10.1%) would have benefited from screenshots. When gag clauses were restricted 3 of 40 (7.5%) contained screenshots and 8 (20%) would have benefited from screenshots. DISCUSSION: The policy change does not appear to have an impact on the prevalence of screenshots in peer-reviewed literature. CONCLUSIONS: Additional steps are necessary to promote the use of screenshots in peer-reviewed literature.

We appreciate the thoughtful response to our brief article entitled “Electronic health record ‘gag clauses and the prevalence of screenshots in peer-reviewed literature.” Dr. Koppel raised several important points that we wish to acknowledge and respond to. Dr. Koppel reminds us that there were 2 Institute of Medicine Reports and an American Medical Informatics Association task force that described electronic health record (EHR) gag clauses and the problems associated with these clauses. There have also been several other stakeholders that have criticized these gag clauses as well as EHR vendors that have argued the clauses are necessary to protect intellectual property. It has taken far too long for a policy change to address the gag clause issue that was identified in 2009 by Dr. Koppel and others. In the over 10 years that it took for a policy change numerous harm events associated with EHRs have occurred that could have potentially been prevented by screenshot sharing to identify safety issues and resulting redesign, improvement, and mitigation. The Office of the National Coordinator for Health Information Technology (ONC) policy change is a major advancement, however, our data suggest it may not be having the desired effect of increasing the sharing of screenshots.

OBJECTIVE: We sought to determine rates of computerized provider order entry (CPOE) patient identity verification and when and where in the ordering process verification occurred. MATERIALS AND METHODS: Fifty-five physicians from 4 healthcare systems completed simulated patient scenarios using their respective CPOE system (Epic or Cerner). Eye movements were recorded and analyzed. RESULTS: Across all participants patient id was verified significantly more often than not (62.4% vs 37.6%). Vendor A had significantly higher verification rates than not; vendor B had no difference. Participants using vendor A verified information significantly more often before signing the order than after (88.4% vs 11.6%); there was no difference in vendor B. The banner bar was the most frequent verification location. DISCUSSION: Factors such as CPOE design, physician training, and the use of a simulated methodology may be impacting verification rates. CONCLUSIONS: Verification rates vary by CPOE product, and this can have patient safety consequences.

Objective: Provider acceptance and associated patient outcomes are widely discussed in the evaluation of clinical decision support systems (CDSSs), but critical design criteria for tools have generally been overlooked. The objective of this work is to inform electronic health record alert optimization and clinical practice workflow by identifying, compiling, and reporting design recommendations for CDSS to support the efficient, effective, and timely delivery of high-quality care. Material and Methods: A narrative review was conducted from 2000 to 2016 in PubMed and The Journal of Human Factors and Ergonomics Society to identify papers that discussed/recommended design features of CDSSs that are associated with the success of these systems. Results: Fourteen papers were included as meeting the criteria and were found to have a total of 42 unique recommendations; 11 were classified as interface features, 10 as information features, and 21 as interaction features. Discussion: Features are defined and described, providing actionable guidance that can be applied to CDSS development and policy. To our knowledge, no reviews have been completed that discuss/recommend design features of CDSS at this scale, and thus we found that this was important for the body of literature. The recommendations identified in this narrative review will help to optimize design, organization, management, presentation, and utilization of information through presentation, content, and function. The designation of 3 categories (interface, information, and interaction) should be further evaluated to determine the critical importance of the categories. Future work will determine how to prioritize them with limited resources for designers and developers in order to maximize the clinical utility of CDSS. Conclusion: This review will expand the field of knowledge and provide a novel organization structure to identify key recommendations for CDSS.

To characterize the variability in usability and safety of EHRs from two vendors across four healthcare systems (2 Epic and 2 Cerner). Twelve to 15 emergency medicine physicians participated from each site and completed six clinical scenarios. Keystroke, mouse click, and video data were collected. From the six scenarios, two diagnostic imaging, laboratory, and medication tasks were analyzed. There was wide variability in task completion time, clicks, and error rates. For certain tasks, there were an average of a nine-fold difference in time and eight-fold difference in clicks. Error rates varied by task (X-ray 16.7% to 25%, MRI: 0 to 10%, Lactate: 0% to 14.3%, Tylenol: 0 to 30%; Taper: 16.7% to 50%). The variability in time, clicks, and error rates highlights the need for improved implementation optimization. EHR implementation, in addition to vendor design and development, is critical to usable and safe products.