title: Mind the Gap. A systematic review to identify usability and safety challenges and practices during electronic health record implementation.
abstract: Decisions made during electronic health record (EHR) implementations profoundly affect usability and safety. This study aims to identify gaps between the current literature and key stakeholders' perceptions of usability and safety practices and the challenges encountered during the implementation of EHRs.
  
  
  
  Two approaches were used: a literature review and interviews with key stakeholders. We performed a systematic review of the literature to identify usability and safety challenges and best practices during implementation. A total of 55 articles were reviewed through searches of PubMed, Web of Science and Scopus. We used a qualitative approach to identify key stakeholders' perceptions; semi-structured interviews were conducted with a diverse set of health IT stakeholders to understand their current practices and challenges related to usability during implementation. We used a grounded theory approach: data were coded, sorted, and emerging themes were identified. Conclusions from both sources of data were compared to identify areas of misalignment.
  
  
  
  We identified six emerging themes from the literature and stakeholder interviews: cost and resources, risk assessment, governance and consensus building, customization, clinical workflow and usability testing, and training. Across these themes, there were misalignments between the literature and stakeholder perspectives, indicating major gaps.
  
  
  
  Major gaps identified from each of six emerging themes are discussed as critical areas for future research, opportunities for new stakeholder initiatives, and opportunities to better disseminate resources to improve the implementation of EHRs.
  
  
  
  Our analysis identified practices and challenges across six different emerging themes, illustrated important gaps, and results suggest critical areas for future research and dissemination to improve EHR implementation.
authors.affiliation: Raj Ratwani, PhD, National Center for Human Factors in Healthcare, MedStar Health, Washington D.C., Email: raj.ratwani@medicalhfe.org.
authors.forename: Raj
authors.initials: R
authors.lastname: Ratwani
authors.forename: Terry
authors.initials: T
authors.lastname: Fairbanks
authors.forename: Erica
authors.initials: E
authors.lastname: Savage
authors.forename: Katie
authors.initials: K
authors.lastname: Adams
authors.forename: Michael
authors.initials: M
authors.lastname: Wittie
authors.forename: Edna
authors.initials: E
authors.lastname: Boone
authors.forename: Andrew
authors.initials: A
authors.lastname: Hayden
authors.forename: Janey
authors.initials: J
authors.lastname: Barnes
authors.forename: Zach
authors.initials: Z
authors.lastname: Hettinger
authors.forename: Andrew
authors.initials: A
authors.lastname: Gettinger
mesh_terms: D001292:Attitude to Computers; D003365:Costs and Cost Analysis; D057286:Electronic Health Records / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D018570:Risk Assessment; D012449:Safety
keywords: Usability; electronic health records; human factors; implementation; safety