Bill of rights (and responsibilities) for EHR users

US Bill of Rights
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This article reviews the rights and responsibilities of clinicians who use electronic health records (EHRs), as proposed by Drs Dean Sittig and Hardeep Singh after years of research and consultation with clinicians, informaticians, and computer scientists.

1) Uninterrupted access to records

Right: Clinicians have a right to have reliable, secure, efficient access to the EHR. When access is interrupted, the patient encounter grinds to a halt, unless the clinician and patient can together remember all the relevant information to support an appropriate evaluation and treatment plan.

A corollary is that clinicians have the right to an EHR installation that responds briskly to user actions, i.e. does not freeze up. Website usability guru Jakob Nielsen observed that a website’s response time of 1 second or shorter “keeps the user's flow of thought seamless” so that they “still feel in control of the overall experience and that they're moving freely rather than waiting on the computer.” When applied to EHRs, this observation suggests that the clinician’s experience suffers when the system freezes for more than 1 second. After a delay of 10 seconds or more, according to Nielsen, website users “start thinking about other things, making it harder to get their brains back on track once the computer finally does respond.” An EHR that freezes up in the middle of patient care processes (i.e. ordering medications) will frustrate clinicians and patients as well as possibly compromise patient safety.

 [Read  about how Nielsen's usability heuristics might be applied to EHRs.]

Responsibility: Clinicians must do their part to ensure the privacy and security of records by protecting their passwords, logging off the EHR when done using it, and viewing only records they should view.

2) No missing data

Right: Clinicians should have full access to data from health care encounters, including visits related to psychiatric issues or substance abuse.

[Read about how health information exchange allows clinicians to access patient data from other health care organizations.]

Responsibility: Clinicians shouldn’t bury themselves in the computer screen, but rather pay attention to the live human patient in the exam room.

3) Succinct patient summaries

Right: Clinicians have the right to summaries of clinical information organized in a logical fashion. For example, the EHR should allow the user to view time trends in vital signs and lab results. Even better would be a problem-oriented view, where all information related to a health condition (e.g. diabetes) would be displayed in a single view.

Responsibility: Clinicians are expected to maintain and update the problem list. “Acute upper respiratory infection” shouldn’t remain on the problem list forever. Orders for lab tests, imaging studies, and prescriptions should be linked with the appropriate problem in order to support billing and allow other clinicians to understand the rationale for the clinical services.

4) Ability to override computer-generated interventions

Right: Clinicians should be able to override EHR alerts. While some alerts provide useful information that would change the clinician’s actions, many alerts are considered bothersome and unnecessary.

Responsibility: When overriding alerts, clinicians should document the reason for overriding alerts (ideally through a simple pull-down menu or free text box). Clinicians should give constructive input to governing committees responsible for maintaining and modifying the alerts.

5) Rationale for clinical decision support

Right: Clinicians need to be able to view the rationale behind alerts and other clinical decision support functions in an EHR. For example, the alert for interaction between fluoxetine and tramadol should mention the specific risks, e.g. serotonin syndrome. This information would allow the clinician to weigh the risks and benefits of overriding the alert.

Responsibility: Clinicians should consider the rationale behind clinical decision support functions before deciding to follow or ignore them.

6) Reliable performance measurement

Right: Clinicians have the right to review and modify the EHR-based methods used to measure quality of care. Performance measures are often not applicable to a specific patient. For example, a woman who had a total hysterectomy for uterine fibroids no longer needs a pap smear. Since a given EHR might not detect such exceptions, the clinician should be able to indicate that the performance measure is not valid.

Responsibility: Clinicians should review performance feedback and take action when needed, i.e. modify their care delivery in the face of valid feedback or notify governing committees when feedback is invalid.

7) Safe electronic health records

Right: Clinicians should expect that medical errors stemming from malfunctioning or poorly-designed EHRs will be promptly investigated and addressed.

Responsibility: Rather than simply complaining amongst themselves about EHR-driven errors, clinicians need to notify appropriate entities and assist in efforts to investigate the errors. Otherwise, the errors will continue.

8) Training and assistance

Right: Clinicians need to adequate training and support for using EHRs. Because a single initial training session may not be enough, ongoing support should be available. Real-time support (during the patient encounter) should be available.

Responsibility: Clinicians must learn to use the EHR at their health care organization. It is not acceptable to allow patient care to suffer due to a lack of competence in entering orders, documenting encounters, or communicating with other providers.

9) Compatibility with real-world clinical workflows

Right: Clinicians need an EHR that supports, rather than dictates, their clinical workflow. Templates for documentation and order entry should make clinical sense. Information should be displayed in a way to help the clinician evaluate the patient’s status (see right #3 above).

Responsibility:  Clinicians should play an active role in redesigning the EHR workspace to fit their needs. This means collaborating with support staff and vendors to identify and address problems.

10) Facilitation of communication, coordination and teamwork

Right: Clinicians have the right to an EHR that facilitates team-based patient care. This requires flexible electronic messaging among all members of the health care team, including the patient.

Responsibility: Clinicians have the responsibility to document their patient encounters in a timely manner, avoid unnecessary copying and pasting between records, and respond to electronic messages.


Nielsen J. Website Response Times. Accessed on August 28, 2014.

Sittig DF and Singh H. Rights and responsibilities of users of electronic health records. CMAJ 2012. DOI:10.1503/cmaj.111599. Accessed on August 26, 2014.

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