1

Human Factors Guidance to Prevent 

Healthcare Disparities with the Adoption 

of EHRs 

Michael C. Gibbons 

Johns Hopkins University

Svetlana Z. Lowry

Information Access Division

Information Technology Laboratory

National Institute of Standards and Technology

Matthew T. Quinn

Information Access Division

Information Technology Laboratory

National Institute of Standards and Technology

U.S. Department of Commerce

Gary Locke, Secretary

National Institute of Standards and Technology

Patrick D. Gallagher, Director

NISTIR 7769
2

Human Factors Guidance to Prevent 

Healthcare Disparities with the Adoption 

of EHRs 

Michael C. Gibbons 

Johns Hopkins University

Svetlana Z. Lowry

Information Access Division

Information Technology Laboratory

National Institute of Standards and Technology

Matthew T. Quinn

Information Access Division

Information Technology Laboratory

National Institute of Standards and Technology

February 2011

U.S. Department of Commerce

Gary Locke, Secretary

National Institute of Standards and Technology

Patrick D. Gallagher, Director

NISTIR 7769
3

Contents

Executive Summary....................................................................................6

Introduction................................................................................................................................. 6

Potential “Digital” Healthcare Disparities.................................................................................. 6

EHR Technical Considerations................................................................................................... 7

Design and Development Guidelines...................................................................................... 7

EHR Evaluation Guidelines.................................................................................................... 8

EHR Monitoring Guidelines................................................................................................. 10

Research Guidelines.............................................................................................................. 11

Conclusions............................................................................................................................... 11

1 Introduction.........................................................................................13

2 Potential “Digital” Healthcare Disparities.............................................15

2.1 History of Healthcare Disparities.................................................................................. 15

2.2 Current Data.................................................................................................................. 16

2.3 Causes and Determinants.............................................................................................. 16

2.4 National Trends............................................................................................................. 17

2.5 Provider Use of Electronic Tools in Healthcare Delivery ............................................ 18

2.5.1 Provider Related Opportunities to Address Healthcare Disparities through Use of 

Electronic Tools.................................................................................................................... 19

2.5.2 Patient and Caregiver Opportunities to Reduce Disparities through Use of Electronic 

Tools 20

2.6 EHR Related Human Factors Risk Characteristics among Target Populations at 

Highest Risk for Healthcare Disparities ................................................................................... 20

2.6.1 Low Socioeconomic Status Groups.......................................................................... 20

2.6.2 Non Native English Speakers or those with Limited English Proficiency ............... 21

2.6.3 People Living with Disabilities................................................................................. 22

2.6.4 Seniors and the Elderly ............................................................................................. 26

2.6.5 Racial and Ethnic Minorities .................................................................................... 28

3 EHR Technical Considerations of Healthcare Disparities....................29

3.1.1 The EHR Development Life Cycle........................................................................... 29

3.1.2 The Potential of EHR Technical Design Issues to Impact Healthcare Disparities... 34

4 Technical Guidance and Recommendations.......................................35

4.1 EHR Design and Development Guidelines................................................................... 35

4.1.1 Conduct Comprehensive Formative and Summative Testing with a Reasonable Set 

of Representative End Users................................................................................................. 35
4

4.1.2 Report Results of the Tests in Common Industry Format (CIF) for EHR Usability 

Test Reports.......................................................................................................................... 36

4.1.3 Accommodate as Many EHR Users as Possible Using Universal Design Principles

36

4.1.4 Include Disparities Oriented Use Cases as Part of the EHR Design and Development 

Process .................................................................................................................................. 37

4.2 EHR Evaluation Guidelines.......................................................................................... 38

4.2.1 Require Documentation of Formative and Summative Testing with a Reasonable Set 

of Representative Target Users as a Prerequisite for EHR Evaluation................................. 38

4.2.2 Require Documentation of Product Features Designed to Increase Usability and 

Accessibility or Documentation of a Lack of Need for any Accommodation among a 

Reasonable Set of Target Users............................................................................................ 38

4.2.3 Require the Development of EHR Operation, Safety, Customer Support and 

Educational Materials that are Culturally and Linguistically Appropriate for a Reasonable 

Set of Representative Target Users as a Prerequisite for EHR Evaluation Process ............. 38

4.2.4 Include User Requirements in Product Specifications as a Prerequisite for EHR 

Certification .......................................................................................................................... 41

4.3 EHR Evaluation and Monitoring Guidelines................................................................ 41

4.3.1 Include Evaluation of EHR Impact on a Target Set of Healthcare Disparities 

Indicators as a Part of the EHR Effectiveness, Post Adoption and Health Impact Evaluation

41

4.3.2 Implement a National EHR Product Registry........................................................... 42

4.4 EHR Research Guidelines............................................................................................. 43

4.4.1 Support Human Factors Research Regarding the Potential Impact, Opportunities and 

Barriers for EHRs to Reduce Healthcare Disparities............................................................ 43

4.4.2 Evaluate the Human Factors Implications of Integrating Patient-Oriented 

Functionality into EHRs ....................................................................................................... 43

4.4.3 Support the Development of Evidence-Based Criteria for Voluntary PopulationOriented Product Certifications ............................................................................................ 43

4.4.4 Evaluate Potential Differences in Information Design Needs, the Impact of These 

Differences and Opportunities for Accommodation across User Populations ..................... 43

4.4.5 Evaluate the Human Factors Implications of Increased Stress (Workload Induced, 

User Environment Induced, Rural/Urban Residence etc) on EHR Accessibility, Usability, 

User Experience and Health Outcomes ................................................................................ 44

4.4.6 Evaluate the Human Factors Implications of the Emerging EHR Health IT 

Workforce Working in Non Clinical Practice Settings (Home, Long Term Care Facility etc) 

on EHR Accessibility, Usability, User Experience and Health Outcomes........................... 44

5 Conclusions ........................................................................................44

Glossary ...................................................................................................45
5

Healthcare Consumers.............................................................................................................. 45

Patients...................................................................................................................................... 45

Providers................................................................................................................................... 45

Culture....................................................................................................................................... 45

Culturally and Linguistically Appropriate Services (CLAS).................................................... 45

Culturally and Linguistically Appropriate Services in Health Care ......................................... 45

Healthcare Disparities............................................................................................................... 47

Safety Net Providers................................................................................................................. 47

Usability.................................................................................................................................... 48

User-Centered Design............................................................................................................... 48

Universal Accessibility ............................................................................................................. 49

Universal Usability ................................................................................................................... 50
6

Human Factors Guidance to Prevent Healthcare Disparities 

with the Adoption of EHRs

Executive Summary

Introduction

This report is derived from several widely recognized international standards and the current 

scientific literature. It is intended for EHR system designers, developers, system architects and 

system engineers. 

The advances in Information Technology (IT) that have been transforming our society have 

tremendous potential to improve healthcare in areas such as clinical care, administrative 

transactions, public health, professional education, biomedical research and consumer health 

(1). In fact, it has been suggested that information technology must play a central role in the 

redesign of the health care system, if substantial improvement in healthcare quality is to be 

achieved (1). There is also a growing interest in understanding the potential role of health IT in 

addressing healthcare disparities (2-4). In order to adequately and appropriately evaluate the 

potential of health IT to address healthcare disparities, health IT adoption and utilization barriers 

must be evaluated and understood. In addition, barriers must be considered from the 

perspective of all potential EHR users. These include the medical provider, support staff, 

patients, family members and caregivers. Finally, the impact of the environment in which the 

technology is used must be understood (e.g. hospital/clinic and home/community). Barriers, 

issues or problems in any one of these areas could impact health IT adoption, utilization and 

ultimately outcomes. If the nature of the problems are such that one population benefits more 

than another, national adoption of health IT could actually increase existing healthcare 

disparities or potentially even create new ones. 

The purpose of this report is to provide technical guidance regarding the design and 

development of EHR systems, which will help to prevent the creation or exacerbation of 

healthcare disparities with the national adoption and utilization of EHR systems.

Potential “Digital” Healthcare Disparities

Several national healthcare reform efforts have called for an increasing role of health IT in 

healthcare delivery as a way to improve efficiency and quality while reducing healthcare costs. 

(1) To date, much of the attention regarding health IT in healthcare has been focused on the 

role of EHRs, Health Information Exchange (HIE), telemedicine, Computerized Physician Order 

Entry (CPOE) systems, e-prescribing and electronic radiologic systems. While national adoption 

data are limited for most forms of health IT, the most recent data for EHRs indicate that EHR 

adoption in U.S. medical offices is approximately 36.1% (5).

Within this context, the role of health IT in addressing healthcare disparities has only recently 

begun to receive consideration (2;4;6). There is great need for federal coordination and 

integration across multiple agencies particularly in the area of technical guidelines and 

standards that will help ensure broad EHR accessibility and usability and thereby reduce the 

possibility of creating or exacerbating healthcare disparities with the roll out, adoption and 

acceptance of EHRs and other emerging health IT products.

Several target populations are at increased risk for EHR related healthcare disparities. These 

include patients of low socioeconomic status and/or limited English proficiency. Patients living 
7

with disabilities, individuals over the age of 65, as well as racial and ethnic minorities are also at 

increased risk of experiencing EHR related healthcare disparities. They are more likely to lack 

access to a regular source of healthcare. Significant mistrust of the medical system has also 

been documented among these populations. This mistrust contributes to an increased 

likelihood of patient refusal and poor adherence to provider recommendations. It also 

contributes to poor doctor-patient communication which leads to limited patient comprehension 

or confusion regarding healthcare information. 

Without EHR design accommodations, these patient contingents will likely also be associated 

with several types of human factors risks that may limit comprehension and understanding of 

EHR information and reduce EHR accessibility or usability. These problems will inevitably lead 

to poor EHR user experiences and limited EHR adoption among high risk patients. They may 

also contribute to poor user experiences among safety net providers (See Glossary) who 

practice in under-resourced settings or otherwise care for large numbers of these underserved 

patients.

Before applying an IT solution, it is important to know what disparities related factors are 

amenable to IT solutions.

EHR Technical Considerations 

There are stages in the EHR design process, where human factors considerations could impact 

EHR usability among users at high risk for experiencing healthcare disparities. Current 

evidence of vendor practices suggest Human Factors Engineering (HFE) and ergonomics 

design principles are not systematically and formally employed during the EHR design process 

(7). 

Robust user-centered design process, based on comprehensive user-centered task analysis 

and the explicit characterization of unique user experience requirements, living environment 

(use context) requirements, cultural requirements and EHR interface requirements is needed. 

This will help ensure the development of accessible and usable EHR systems for target end 

users at increased risk of experiencing healthcare disparities and safety net providers caring for 

these patients.

Design and Development Guidelines

Universal usability approach will significantly reduce the likelihood of healthcare disparities with 

the adoption of EHRs. Generally, these recommendations focus on equipping the EHR design 

team with the information necessary to understand potential healthcare disparities challenges 

related to use of the EHR. These recommendations also focus on ensuring that this information 

is then used to improve EHR system usability via the iterative design process.

Conduct comprehensive formative and summative testing with a reasonable set of 

representative target users

To help ensure broad EHR accessibility and usability, it is imperative that usability testing

involve those who are likely to be using the system. 

Designers and Developers should use the Common Industry Format (CIF) for EHR 

usability test reports

The Common Industry Format (CIF) for Usability Test Reports is intended for use in reporting 

the results of summative usability testing (8). Usability of EHR systems is a key factor in 

predicting successful deployment. EHR system developers and manufacturers must subject 

EHRs to usability testing at various stages in a product’s development. Testing should involve 
8

(1) subjects who are representative of the target population of EHR users, (2) representative 

tasks, and (3) measures of efficiency, effectiveness and subjective satisfaction. 

Accommodate as many EHR users as possible via the use of universal design principles

To ensure that as many potential EHR users as possible are able to use emerging EHR

systems safely and effectively, a Universal Design strategy (See Glossary) should be adopted. 

Accommodating a broader spectrum of users and user contexts will require designers to 

consider a wider range of designs. Many of the design accommodations can be incorporated 

without significant impact on developmental time or expense. Once completed, these

improvements often lead to innovations that benefit all users (9).

Include disparities-oriented use case scenarios and user contexts as part of the EHR

design and developmental planning process

In an effort to reduce the likelihood of design flaws that disproportionately impact health patients 

from healthcare disparities populations or safety net providers it will be important to enhance 

development process by considering disparities-oriented use case scenarios and user contexts 

to guide the planning effort. In the absence of demonstrated disparities expertise on the part of 

EHR designers and developers, it cannot be assumed that all the necessary considerations can 

or will be made. Disparities-oriented use cases may include:

1) Adult caregiver of a senior relative use case

In many families, adult children caring for elderly parents is becoming increasingly 

common. This may be even more likely among patients from disparity populations who 

may lack resources to provide alternate care arrangements for their aging relative. The 

cognitive and physical demands and stress of care giving combined with childrearing, 

homemaking and also additional employment may create critical challenges for the safe 

and effective use of EHRs. In other words, the consideration of these broader patient user 

contexts, may be as critical for understanding EHR usability by patients, as understanding 

clinical workflows in the hospital is for understanding provider EHR usability.

2) Patient/Caregiver with limited English proficiency use case

Providing care to patients with limited English proficiency creates challenges for all 

involved parties. This is no less true in the context of EHR-mediated care. 

Misunderstandings or confusion caused by a poorly designed EHR, in the context of 

marginal English proficiency, may prove more challenging and more difficult to even detect 

than complete inability to use the available system unless these types of use cases are 

employed. 

3) EHR use in the context of doctor-patient cross cultural or communications 

barriers use case 

In some cultures, major decision making is considered a family or at least a combined 

activity between a husband and a wife. However, informed consent and access to EHR 

information is currently considered largely from the Western perspective (i.e. single users 

and individual rights). Usability, user experience and satisfaction implications with the use 

of such an EHR are not likely to be optimal. There should be design accommodations that 

could help address the challenges created by these cultural differences.

EHR Evaluation Guidelines

Documentation of summative testing with a reasonable set of representative target users 

should be required 
9

To ensure that all end user contingents are defined and user requirements are implemented in 

the product development cycle, summative testing report in CIF format should be available.

Require documentation of product features designed to ensure accessibility; and any 

accommodations needed for users with disabilities

To ensure that vendors are making appropriate design enhancements specifically for the 

purpose of improving identified limitations among target users, it is recommended that 

documentation of included product features be provided as part of EHR evaluation process.

Require the development of EHR operation, safety, customer support and educational 

materials that are culturally and linguistically appropriate for a reasonable set of 

representative target users 

Writing clear EHR functionality related system messages and instructional materials is critically 

important as an increasing variety of users adopts EHRs. The following specific 

recommendations are made for instructional materials for both paper and electronic formats 

(10). These should not be viewed as an exhaustive nor comprehensive set of 

recommendations. Rather these can be considered as a starting point for the development of 

more effective and usable EHR instructional materials.

1) Put instructions where (at specific point on the screen) they are needed – not all together 

at the top of the page. 

2) Put instructions above/before they are needed – not after. 

3) Put instructions in logical order first task, first; last task, last. 

4) Put warnings about consequences before – not after – the user is likely to act. 

5) Do not highlight the action option until EHR users have been given all available options. 

6) The order of buttons must match the order of the instructions. 

7) Start each instruction on a new line. 

8) Write directly to the EHR user. 

9) Keep each instruction as short as possible. 

10) Watch the tone. Help EHR users, don’t threaten them. 

11) Write in the positive. 

12) Put the context before the action. 

13) Be consistent in the language of the instructions. 

14) Do not use gender-based pronouns. 

15) Use simple English words. 

16) Be consistent in the language that is used. 

17) Do not use technical, computer jargon. 

18) Be explicit in naming buttons. 

19) Cover all important situations. 

20) Consider EHR users’ likely mistakes. 

21) Understand the audience for messages about EHR problems. 

22) Understand the context for messages about problems. 
10

23) Messages and instructional material should be designed and tested for specific clinician 

or patient, caregiver and consumer use cases and contexts. 

Include user requirements in product specifications

To help ensure that the best match is achieved between EHR features and user needs, it is 

recommended that user requirements be included in all EHR product specifications. This will 

allow potential users to make informed choices regarding the applicability of a given EHR 

product for a given set of user needs. Common Industry Specification for Usability–

Requirements (CISU-R) http://zing.ncsl.nist.gov/iusr/documents/whatistheCISUR.html

EHR Monitoring Guidelines

Include evaluation of EHR impact on a target set of healthcare disparities indicators as a 

part of the EHR effectiveness, post adoption and health impact evaluation

All efforts to document the effectiveness of EHR systems should also include specific 

investigation of the EHR impact on healthcare disparities. The EHR healthcare disparities 

indicator set has to be defined. Once defined, it should be used as the basis for conducting 

ongoing healthcare disparities impact assessments. This work should be supplemented by 

additional qualitative research among safety net providers and patients from disparities 

populations, to provide additional information regarding the nature, character, quality, magnitude 

and emergence of new determinants or elimination of current determinants of Healthcare 

disparities impacted by EHR adoption and use.

Implement a National EHR Product Registry

Given the number and diversity of EHR developers and vendors as well as the diverse and 

dynamic needs of potential EHR users, it is recommended that a National EHR Product Registry 

be developed for all certified EHR products and other products which in the future are integrated 

into or otherwise linked with an EHR system. This registry should have standardized reporting 

requirements as outlined below. This registry would provide significant scientific research, 

consumer research, product safety and patient educational benefit, for potential EHR 

customers, users and providers.

EHR Product reporting recommendations targeting EHR Vendors

Standardize EHR technical elements & design feature reporting

Certified EHR vendors should be required to report a standard set of technical and design 

features. The reporting requirements should be developed through a consensus driven process 

of public and private partners including Healthcare disparities, disabilities, and underserved 

population’s expertise. Reported data should be publicly available.

EHR product evaluation reporting 

Certified EHR vendors should be required to report a standard set of EHR evaluation 

information. In the future this should include any target user-oriented voluntary certifications 

received by the EHR product. Evaluation information should include information about user 

requirements and product specifications.

EHR Product reporting recommendations targeting Providers and Healthcare Systems 

Adverse event reporting

The National EHR Product Registry should facilitate voluntary, provider and healthcare system 

adverse event reporting.

Provider Feedback
11

The registry should also facilitate provider feedback regarding the EHR challenges problems, 

malfunctions, errors experienced while using the system.

EHR Product reporting recommendations targeting Patient, Consumers and Caregivers 

Patient education

The National EHR Product Registry should provide culturally and linguistically appropriate 

patient educational information regarding certified EHR and associated technology. The 

information should be supplied by the product vendors but should comply with recognized 

federal standards for providing Culturally Linguistically Appropriate Services (See Glossary) and

communicating information to diverse populations (11).

Consumer feedback

The National EHR Product Registry should facilitate patient and consumer feedback about EHR

systems.

Research Guidelines

Evaluate potential differences in information design needs, the impact of these 

differences and opportunities for accommodation across user populations

It is not clear whether or not different populations of users based on race/ethnicity, culture or 

socioeconomic status have differing information design needs and whether or not such needs 

can impact healthcare disparities. Because information architecture is at the heart of any EHR 

design, usability and understanding, research in this area may have significant import for 

addressing healthcare disparities via EHR systems.

Evaluate the Human Factors implications of increased stress (workload induced, user 

environment induced, rural/urban residence, etc) on EHR accessibility, usability, user 

experience and health outcomes

To date, most of the research regarding stress and human-computer interaction has been done 

in the context of the work environment. However, as healthcare is increasingly being delivered 

in the home and in community-based settings and as patients increasingly become engaged in 

their EHRs, more research needs to be done to understand the potential impact of the home 

environment on EHR accessibility, usability, user experience and health outcomes.

Evaluate the Human Factors implications of the emerging EHR Health IT workforce 

working in non-clinical practice settings (home, long-term care facility, etc) on EHR 

accessibility, usability, user experience and health outcomes.

A myriad of support personnel will inevitably be EHR system users. These include clinical

office/practice managers, receptionist/schedulers and technical support personnel. Without 

these individuals involved, many providers would not be able to accomplish needed EHR data 

entry or report/summary requirements. Also there is an emerging health workforce comprised of 

those individuals who provide or support care primarily in home and community settings

(Community Health Workers, Patient Navigators etc). It is likely that in order to maintain 

appropriate oversight and management, as well as quality assurance and efficiency, these 

individuals will increasingly be using wireless handheld and tablet or laptop-based mobile 

devices to input data into the EHR in real time, in the field, at the “point of care”. The 

implications of this emerging workforce on health, healthcare outcomes and healthcare 

disparities need to be evaluated.

Conclusions

Significant scientific evidence attests to the fact that healthcare disparities exist, they are 

intractable and associated with increased healthcare costs, premature morbidity and excess 
12

mortality. Wide adoption and meaningful use of EHR systems by providers and patients may 

impact healthcare disparities. Predicting exact impacts is a challenge because the effects of 

EHR utilization on Healthcare disparities are likely to multiple, nuanced, cumulative and at times 

indirect. Disparities could improve, if EHR use and benefits are equitably distributed across user 

populations. On the other hand, disparities could worsen, if some providers are not able to use 

EHRs or some patients are not able to benefit from them. 

The field of human factors engineering and ergonomics has made considerable contributions to 

our understanding of the possible barriers and potential solutions needed to ensure broad 

accessibility and usability of emerging EHR systems. Unfortunately, most of this knowledge and 

expertise does not appear to be routinely considered during the EHR design and development 

process (7). In addition, little research along these lines can be found in the disparities literature. 

Few studies of EHR usability or health impact have been done from a healthcare disparities 

perspective. As such, much more research is warranted. There is also considerable need for 

federal policy leadership in this area. This leadership will help ensure that all providers are able 

to use EHRs and also help ensure that all patients are able to benefit from EHR use. Finally, 

given what is already known, much can be done now to reduce the risk of creating or 

exacerbating healthcare disparities. Product enhancements can be made by addressing key 

disparities-related design issues and by incorporating human factors engineering principles into 

the EHR design and development process. Significant progress along these lines, will inevitably 

improve provider EHR adoption, help lead to reductions in healthcare disparities among affected 

populations and catalyze improvements in healthcare quality for all.
13

1 Introduction

The Health Information Technology for Economic and Clinical Health Act’s (HITECH Act’s) 

provisions to drive adoption and meaningful use of Electronic Health Records (EHRs) holds 

great promise in supporting improvements in the quality, efficiency and effectiveness of care 

delivery. Replacing paper-based processes with electronic ones will have profound implications 

on both how care is delivered and how workers in healthcare organizations perform their jobs.

Recently, several national healthcare improvement efforts (12;13) have fostered interest in the 

use of health IT in healthcare. These consider information technology as playing a central role in 

the redesign of the healthcare system if a substantial improvement in healthcare quality is to be 

achieved (1). Within this context, the role of health IT in addressing healthcare disparities has 

only recently begun to receive consideration (2;4;6). In order to adequately and appropriately 

evaluate the potential of health IT to address healthcare disparities, health IT adoption and 

utilization barriers must be understood. It will also be important to understand the potential 

opportunities to effectively address healthcare disparities through health IT. Such analyses will 

enable an evidence-based approach to the design, development and deployment of appropriate 

electronic tools and provide the best foundation for using health IT to help address healthcare 

disparities. 

With the introduction of EHRs, it is vitally important that EHR developers and healthcare 

organizations design, develop and implement EHRs in such a way that supports meaningful use 

by all users, including those with disabilities, and not introduce a “digital divide.”

While EHRs are principally used by healthcare workers, patients interact with these systems 

directly (e.g. shared use of a display in an exam room) and indirectly through their outputs (e.g. 

copies of patient records, discharge instructions). To gain the intended benefits of this 

technology, EHR systems must display or deliver information in a manner and structure that is 

suitable for their needs and preferences. Therefore, it is vitally important that EHR developers 

and healthcare organizations implement meaningful use requirements and other functionalities 

involving patients in a way that supports the patients, populations and communities that they 

serve.

This paper will provide technical guidance for EHR developers and healthcare organizations 

regarding the design, development and implementation of EHR systems to prevent the creation 

or exacerbation of “digital disparities” with the national adoption and utilization of EHR systems, 

in the workplace and among patients. Through identification and application of best practices, 

guidance and standards in software usability and accessibility, system developers and 

healthcare organizations can ensure that EHR system support meaningful use by users that 

reflect the make-up of the healthcare workforce and patient-base.

Significant, pervasive and intractable healthcare disparities have been convincingly documented 

at all levels of the healthcare system. A large body of work has demonstrated the existence of 

these disparities across racial and ethnic lines (14). However they can also be demonstrated 

across individuals living with disabilities, people of low socioeconomic status and among those 
14

with limited English proficiency. In addition, several national trends suggest the scope and 

magnitude of these disparities are likely to increase. Healthcare disparities are associated with 

poorer health outcomes, premature death and increased personal and healthcare system costs 

(15;16).

There is evidence that EHR systems represent one promising way of enhancing the quality of 

healthcare, reducing waste, fraud and inefficiency in the healthcare system, improving health 

outcomes and reducing healthcare disparities. Less evident, however, is the ability of all 

healthcare organizations to use health IT effectively in the achievement of these goals, given 

their specific contexts and populations served. Most of the focus within the healthcare system 

has been on the potential of EHR systems and other decision support tools for healthcare 

providers. Interestingly though, outside the healthcare system, much of the focus has been on 

patient- and consumer-oriented (See Glossary) decision support tools. Indeed, it is envisioned, 

that future EHR systems will provide decision support to healthcare providers and patients,

alike. 

EHRs should be designed to take account of the people who will use them. Therefore, all 

relevant user groups should be identified. It is likely to be a potential contributor to the 

development of healthcare disparities. The extent to which products are usable and accessible 

depends on the context of use. The context of use is a major source of information for 

establishing requirements and an essential input to the design process (17).
15

2 Potential “Digital” Healthcare Disparities 

2.1 History of Healthcare Disparities

Over the last two decades, scientific research examining variability in clinical practice patterns, 

has begun to accumulate (18;19). In the mid eighties, the report of the Secretary’s Task Force 

on Black and Minority Health (20) highlighted, for the first time, at a national level in the United 

States, the fact that the health of African-Americans and minorities significantly lagged behind 

that of Whites. Upon closer examination it was revealed that problems associated with quality 

healthcare and racial and ethnic healthcare differences were in fact linked. Additionally, it 

became recognized that certain community, environment and societal factors including stress 

(21;22), early life experiences (23), social capital (24), and income inequality (25;26) seemed to 

exert significant effects on health, independent of personal behavior (27). Several efforts were 

undertaken to clarify the impact of these “nonmedical” factors on healthcare outcomes. By the 

late 1990’s, the scientific evidence seemed to indicate that issues of healthcare disparities, 

clinical practice variation, substandard medical care and socio-environmental determinants of 

health, were all associated with the quality of healthcare experienced by patients (3). This work 

culminated with the 2003 release of a report entitled “Unequal Treatment: Confronting Racial 

and Ethnic Disparities in Healthcare” (1). This report found that within the United States, even 

among individuals with access to care, significant racial and ethnic disparities existed. The 

report also found that these disparities were associated with higher morbidity and mortality and 

were therefore unjustifiable (14). This report has subsequently spurred significant local and 

national effort to address these disparities. While some progress has been made, much more 

work is needed to enable significant, sustained improvements.

Generally, the causes of healthcare disparities are held to be related to three sets of factors. 

Firstly, patient related factors that include lack of a regular source of care, poor patient-provider 

communications, mistrust in the medical system, cultural insensitivity and inability to understand 

medical providers. Secondly, provider related factors that include bias and clinical uncertainty 

when interacting with racial and ethnic minority patients. Language barriers between providers 

and patients also may play a role in the establishment of healthcare disparities. Finally, 

healthcare system factors include the fragmentary nature of healthcare delivery and the 

organization of the healthcare establishment as well as financial incentives. Despite significant 

effort, healthcare disparities are not improving. In addition, without effective intervention, over 

the course of the next few years, healthcare disparities are expected to increase. This increase 

will further strain on the fragile and challenged US Healthcare system. 

The development of computer technology has created an information gap that has grown faster 

and wider over recent years. As healthcare systems and providers rely more on information from 

the Internet to guide day-to-day care, the disparity between the information “haves and have 

nots” expands. Awareness of the disparity and its impact on healthcare is the first step in 

narrowing the information gap. Reasons for the gap are complex and multi-factorial, as are the 

solutions. The information gap will likely remain wherever there is poverty, illiteracy, or 

indifference. In terms of healthcare, this can mean disparity in information available to 

healthcare providers and the continuation of outdated, less effective treatment approaches. 

According to Fowler (2003), “The feedback loop between research and practice will become 

smaller, tighter, and faster” (p. 11), resulting in healthcare providers having greater and quicker 

access to the latest healthcare information. For the disconnected public, it can mean less 

awareness of health problems and how to manage them, and less self-empowerment. (28)
16

2.2 Current Data

Today, evaluating and addressing healthcare disparities is considered an integral part of 

improving healthcare quality and outcomes. The National Healthcare Disparities Report (NHDR) 

is an annual report commissioned by congress to monitor the nation’s progress toward 

eliminating healthcare disparities among various racial, ethnic and income groups and other 

priority populations (29). Three key themes emerged in the 2009 NHDR. Firstly, disparities 

related to race, ethnicity, and socioeconomic status still pervade the American healthcare 

system. Although varying in magnitude by condition and population, disparities are observed in 

almost all aspects of healthcare, including: 1) across all dimensions of healthcare quality 

(including effectiveness, patient safety, timeliness, and patient-centeredness); 2) across all 

dimensions of access to care (including facilitators and barriers to care and healthcare 

utilization); 3) across many levels and types of care (including preventive care, treatment of 

acute conditions, and management of chronic diseases); 4) across many clinical conditions 

(cancer, diabetes, end stage renal disease, heart disease, HIV disease, mental health and 

substance abuse, and respiratory diseases); 5) across many care settings (including primary 

care, home healthcare, hospice care, emergency departments, hospitals, and nursing homes); 

6) within many subpopulations (including women, children, older adults, residents of rural areas, 

and individuals with disabilities and other special healthcare needs) (29).

Secondly the report indicated that previously identified disparities are not improving. Measures 

of quality include effectiveness (the percentage of patients with a disease or condition who get 

recommended care), patient safety, and timeliness. Measures of access to care include health 

insurance coverage, utilization of general health services, and barriers to care (29). 

Finally the report suggests that some disparities merit particular attention, especially care for 

cancer, heart failure, and pneumonia. Findings from the 2009 NHDR show that disparities in 

care for cancer, heart failure, and pneumonia exist across populations. Although quality of 

hospital care for heart failure and pneumonia has improved overall, care for Whites continues to 

improve at a higher rate than for minority populations. Thus, quality improvement has not 

necessarily translated to disparities reduction, which is critical for high-quality care. Low rates of 

colorectal cancer screening and other cancer screenings among minorities may be due to 

cultural attitudes and patient perceptions, such as, the belief that screening is not necessary. In 

addition, patients may have problems paying for follow-up visits to complete screening and may 

have logistical problems getting to appointments. Similarly, pneumococcal vaccination rates 

may be lower for Blacks and Asians because of distrust in the effectiveness of vaccines and 

perceptions that vaccines are not necessary (29).

2.3 Causes and Determinants

Before applying an IT solution, it is important to know what disparities related factors are 

amenable to IT solutions. As such, it is necessary to first present a short discussion of the major 

determinants of healthcare disparities.

Determinants of healthcare disparities exist on at least three levels. These include patient-level, 

provider-level and healthcare system factors. In terms of patient-level factors, racial and ethnic 

minority patients are more likely to refuse recommended services, adhere poorly to treatment, 

and delay seeking care. These behaviors and attitudes can develop as a result of a poor cultural 

match between minority patients and their providers, mistrust, misunderstanding of provider 

instructions, poor prior interactions with healthcare systems, or simply from a lack of knowledge 
17

of how to best use healthcare services (14). However these differences in refusal rates are 

small and cannot fully account for observed disparities. The responses of racial and ethnic 

minority patients to healthcare providers are also a potential source of disparities. If patients 

convey mistrust, refuse treatment, or comply poorly with treatment, providers may become less 

engaged in the treatment process. Patients then, are less likely to receive more vigorous 

treatments and services. Patients’ and providers’ behavior and attitudes may therefore influence 

each other, but reflect the attitudes, expectations, and perceptions that each has developed in a 

context where race and ethnicity are often more salient than these participants may realize (14).

Provider-related factors include provider bias (or prejudice), clinical uncertainty when interacting 

with minority patients, and provider beliefs (or stereotypes) about a given patient may influence 

healthcare disparities (14). The doctor can be viewed as operating with prior beliefs that will be 

different according to age, gender, socioeconomic status, and race or ethnicity of the patient. 

When these beliefs are considered alongside the information gained in a clinical encounter, both 

may influence medical decisions (14). If the physician has difficulty accurately understanding the 

symptoms or other diagnostic information, then he or she is likely to place greater weight on his 

or her beliefs, biases and stereotypes. The consequence is that treatment decisions and 

patients’ needs are potentially less well matched and may tend to increase healthcare 

disparities (14). 

Finally, healthcare system factors including language barriers pose a problem for many patients. 

Nearly 14 million Americans are not proficient in English. As many as one in five patients speak 

Spanish. Similarly, time pressures on physicians may hamper their ability to accurately assess 

the symptoms of minority patients, especially when cultural or linguistic barriers are present. 

Perhaps more significantly, changes in the financing and delivery of healthcare services 

including cost-control efforts and the movement to managed care, may pose greater barriers to 

care for racial and ethnic minorities than for non-minorities. This may happen through incentives 

to increase efficiency or reduce expenditures/costs (14).

2.4 National Trends

Several population trends form the basis for growing concern that healthcare disparities will 

increase in coming years, producing significant stress on an already challenged healthcare 

system. First, the U.S. population is expected to reach approximately 400 million. The Census 

Bureau projects that the U.S. population will continue to grow, to 420 million persons by year 

2050. This growth is due to increasing survival rates, declining mortality rates, high fertility rates 

and significant immigration (30).

Second, the proportion of seniors in the U.S. population (aged > 65) is expected to increase 

from just over 12% in 2000 to approximately 20% in 2030. This translates into an increase from 

35 million to approximately 71 million seniors (31). The number of persons aged >80 years is 

expected to increase from about 9 million in 2000 to 19 million in 2030. These changes are also 

occurring because of an increase in the average life span combined with elevated fertility rates 

after World War II (the "Baby Boom") (31). 

Third, the United States, like other developed countries, has experienced a shift in the leading 

causes of death, from infectious diseases and acute illnesses to chronic diseases and 

degenerative illnesses. In 2001, the leading causes of death in the United States were primarily 

cardiovascular diseases and cancer. The leading causes of death around the time of the birth of 

the United States were primarily infectious and parasitic diseases (31). In the United States, 

approximately 80% of all seniors have at least one chronic condition, and 50% have at least two 

(31). 
18

Fourth, the United States is also becoming more racially and ethnically diverse. This is occurring 

primarily due to immigration. Although most immigrants tend to be young adults, U.S. 

immigration policy has favored the entry of parents and other family members of these young 

immigrants. At the same time, major racial and ethnic groups age at different rates due to 

fertility, mortality, and immigration differences within these groups (30).

While about 81% of the population was White in 2000, that figure is projected to fall to 72% by 

year 2050. Increases will be most dramatic for Asians and for persons in the “other races” 

category (which includes American Indians and Alaska Natives, Native Hawaiians and other 

Pacific Islanders, and individuals who identify with two or more races). Between 2000 and 2050, 

the number of Asians is expected to increase by 22.7 million, an increase of 213%, while the 

number in the “all other races” (which includes persons who identify with two or more races) 

category will increase by 15.3 million, or 217%. The population of Hispanic or Latino origin is 

projected to steadily increase as a percentage of the total U.S. population through 2050, rising 

from 12.6% in 2000 to 24.4% in 2050 (30).

Taken together, these trends (the increasing population size, increasing proportions of racial 

and ethnic minorities, the increased prevalence of chronic diseases and significantly increasing 

numbers of older persons) represent a challenge for the U.S. healthcare system. As the U.S. 

population ages and becomes more diverse, the social, medical and economic demands on the 

health and social care systems will grow. Increasing demand will tend to also further increase 

healthcare costs. As such, critical questions remain regarding the best mechanisms for health 

system organization, delivery, access and healthcare financing. Those patients and populations 

with fewer resources to deal with these challenges (seniors, immigrant, minorities, the poor and 

disabled) will be disproportionately affected, thereby increasing the gaps in healthcare access, 

quality and outcomes between the underserved and the general population. (30).

2.5 Provider Use of Electronic Tools in Healthcare Delivery

To date, much of the attention regarding health IT in healthcare has been focused on the role of 

EHRs, HIE, telemedicine, CPOE systems, e-prescribing and electronic radiologic systems. 

While national adoption data are limited for most forms of health IT, the most recent data for 

EHRs indicate that EHR adoption in U.S. medical offices is 36.1% (18). Providers primarily use 

EHR systems for electronic notes, viewing/ordering labs/x-rays and e-prescribing. Several 

factors tend to be associated with higher EHR adoption rates. These include group practices 

with a larger number of physicians, a higher number of available exam rooms and higher daily 

patient volumes (5).

Data from the 2005 and 2006 National Ambulatory Medical Care Survey (NAMCS) and National 

Hospital Ambulatory Medical Care Survey (NHAMCS) indicate that EHR adoption is lower 

among providers serving Hispanic or Latino patients who are uninsured or rely on Medicaid. It 

also found lower EHR adoption among providers of uninsured non-Hispanic Black patients than 

for providers of privately insured non-Hispanic White patients. Primary care providers in private 

solo or small group practice have the lowest adoption rate (5.7 percent), whereas those in other 

office settings (including HMOs, faculty practice plans, and urgent care centers) have the 

highest adoption rate (38.3 percent) (32). A study has also shown that specialty physicians are 

more favorable towards adopting EHR systems than primary care physicians. The lower 

adoption rate among primary care physicians can be attributed to the complex workflows that 

exist in their offices leading to non-standardized workflow structures and practices.(33)
19

2.5.1 Provider Related Opportunities to Address Healthcare Disparities through Use of 

Electronic Tools

Several provider-level determinants of healthcare disparities may be impacted by health IT. For 

example, a major goal of many of the provider-oriented health IT tools is to make pertinent 

patient information available to providers at the point of care. This information help reduce 

clinical uncertainty related to certain unclear/incorrect patient information found in handwritten 

medical records. In the absence of needed information or in the presence of unclear/ambiguous 

data, providers may undervalue or under appreciate patient-specific information, over-weigh 

beliefs, assumptions, biases or stereotypes about certain types of patients (4). If the needed 

information is clearly presented to the clinician in the EHR, it should increase the use of clear 

and accurate patient information by obviating the need for relying on less appropriate data. Over 

time, this is likely to have the cumulative effect of promoting high quality personalized care 

across patients and reducing related healthcare disparities (4).

EHRs also provide physicians with information about appropriate treatment options, thus 

providing clinical decision support (4). Health IT tools, through reminders, quality reports or 

clinical benchmarking may also provide clinical decision support by generating feedback to 

providers regarding their clinical performance. Reminders and quality reports provide feedback 

to providers about the quality of care they provide to a particular patient during a clinical 

encounter or about the care they have provided to a group of patients over a time. If these 

reports include specific disparity indicators, it can help reduce those disparities by exposing 

unrecognized clinical practices which fall short of accepted standards and guidelines. These 

reports may also help by highlighting a provider’s performance across all patients. Providers 

may then work to reduce identified disparities by focusing on those areas which need 

improvement (4).

Health IT tools like EHR systems, e-mail, e-consultation, e-prescribing and CPOE systems

function to connect physicians with other healthcare professionals and other people (7). . They 

also facilitate reduction in healthcare disparities in patient care by providing ready access to the 

needed clinical knowledge for better diagnostic and therapeutic decisions. Other forms of health 

IT tools, including telemedicine, remote monitors and sensors, patient e-mail the internet and 

social media, connect providers and healthcare systems to their patients and caregivers (34). 

These tools may reduce disparities by providing education and support to disparity populations 

and by enabling access to care, otherwise unavailable. However, disparities tend to actually 

increase if these tools are used unevenly across populations, or they are designed in a way that 

precludes safe and appropriate use by patients and caregivers with limited English proficiency, 

limited educational backgrounds, disabilities or limited ability to access these tools (4).

Another way in which health IT tools that connect providers with patients may impact healthcare 

disparities is by enabling increased monitoring of essential and critical patient clinical 

parameters among racial and ethnic minority patients. Since many patients often fail to 

adequately monitor or self-mange their conditions, remote monitoring via patient sensor 

(“smart”) technology, can enable direct delivery of patient data (e.g., glucose levels, weight, vital 

signs, falls, psychological or musculoskeletal stress/injury, etc.) to a device or even an EHR. 

These data (e.g.. blood sugar, weight gain/loss) could facilitate better clinical management and 

disease control resulting in lower complication rates (e.g., blindness, renal failure, limb loss) and 

delay in disease progression (e.g., diabetes, congestive heart failure) by potentially narrowing 

the disparities. These tools can also facilitate a more stable relationship between a patient and 

the provider by enabling patients to overcome barriers to regular communication and access to

care or otherwise, in maintaining a patient-provider relationship. Having a regular source of care 

has been described as a significant determinant of healthcare disparities (35;36). By improving 

and stabilizing patient-provider communication and relationship, these tools may also help 
20

promote enhanced patient involvement in care, facilitate shared decision-making and strengthen 

patient-centered care. These factors are recognized as some other important determinants of 

healthcare disparities and also, essential for high quality healthcare (37-43).

2.5.2 Patient and Caregiver Opportunities to Reduce Disparities through Use of 

Electronic Tools

There are many new opportunities for patients and caregivers to utilize technology to manage

their health and the care provided. The Institute of Medicine, Centers for Medicare and Medicaid 

Services and other bodies are beginning to emphasize that care should be provided not only 

during face-to-face visits, but also via a variety of formats. E-Health and health IT tools should 

be used to increase patient access, enhance patient engagement, re-engineer patient-centered 

care and foster the continuous healing relationships needed to appropriately manage chronic 

illnesses (1;44;45). These opportunities can potentially reduce the incidence or impact of 

healthcare disparities among affected populations by improving access to care.

Health IT tools designed primarily for patients could in the future, become important options to 

support patient health education. Due to the prevalence of health literacy challenges which 

occur disproportionately among minority populations, many patients appear to lack the 

necessary skills to fully understand or comprehend provider instructions, medication and 

healthcare product labels or adhere to complex self-management (46;47). Incomplete or partial 

understanding of health and healthcare issues may fuel lack of trust in the healthcare system. 

Mistrust has been linked to devaluing or disregarding provider instructions and patient nonadherence among certain disparity populations (35;48-52). As such, technology based 

approaches to providing culturally, linguistically and cognitively appropriate and accessible 

health education may represent one way to build patient trust, increase access to needed health 

care services, enhance patient engagement in their healthcare management and decisionmaking and ultimately improve disparate outcomes (3). 

To date, much of the patient-oriented focus on health IT has been on the role of Personal Health 

Record (PHR) systems. PHRs, majority of them being Internet-based, are tools that may be 

linked with the EHRs. They allow people to access, input, change, coordinate and control their 

health information. The major difference between a PHR and an EHR is the lack of patient 

access and control of the EHR (44). In addition, other patient-oriented health IT tools as well, 

promise to support patient’s health-related behaviors. By enhancing social support and 

interaction, these tools may enhance medication adherence (reminders systems), patientprovider communication (EHR, emails), physician cultural competency (crowdsourcing 

technologies) and healthy lifestyles (location based social media). These, thereby reduce

disparities particularly among racial and ethnic minority populations where utilization of social 

media and mobile applications is significantly higher than among the White populations (53;54).

2.6 EHR Related Human Factors Risk Characteristics among Target Populations at 

Highest Risk for Healthcare Disparities

2.6.1 Low Socioeconomic Status Groups

The U.S. Census Bureau reports that real median household income in the United States in 

2009 was $49,777 which was unchanged from 2008. The nation's official poverty rate in 2009 

was 14.3 percent, up from 13.2 percent in 2008. There were 43.6 million people living in poverty 

in 2009, up from 39.8 million in 2008 — the third consecutive annual increase. Households in 

the West and Northeast had the highest median household incomes. Also in 2009, the earnings 

of women who worked full time, year-round remained at 77% of that for corresponding men. On 

the other hand the real median earning of men who worked full time, year-round rose by 2.0 
21

percent between 2008 and 2009, from $46,191 to $47,127. For women, the corresponding 

increase was slightly less at1.9 %, from $35,609 to $36,278 (55).

The poverty rate in 2009 was the highest since 1994, but was 8.1 percentage points lower than 

the poverty rate in 1959, the first year for which poverty estimates are available. The number of 

people in poverty in 2009 is the largest number in the 51 years for which poverty estimates are 

available. In 2009, the family poverty rate and the number of families in poverty were 11.1 

percent and 8.8 million, respectively, up from 10.3 percent and 8.1 million in 2008. Finally, the 

poverty rate and the number in poverty increased across all types of families: married-couple 

families (5.8 percent and 3.4 million in 2009 from 5.5 percent and 3.3 million in 2008); femalehouseholder-with-no-husband-present families (29.9 percent and 4.4 million in 2009 from 28.7 

percent and 4.2 million in 2008) and for male-householder-no-wife-present families (16.9 

percent and 942,000 in 2009 from 13.8 percent and 723,000 in 2008) (55).

Individuals from low socioeconomic status groups are at increased risk of healthcare disparities 

because they are much more likely than the general population to lack appropriate ongoing 

access to healthcare services. It is important to note that the risks extend to both providers and 

patients from low socioeconomic groups. Although individuals who come from low 

socioeconomic groups who then become healthcare providers often achieve a level of personal 

income above that which could be achieved otherwise, they also are more likely to practice in 

low socioeconomic status communities providing care in low resource facilities, providing care 

for the poor and uninsured. As such these providers are less likely to own, purchase or utilize 

EHRs (32). Thus the patients seen by these providers will be unable to access the benefits 

derived from receiving care from a provider who utilizes an EHR. In addition the low 

socioeconomic status patients and consumers themselves are much less likely to use or access 

information via an EHR or Personal Health Record (PHR) even if one is available (32;44;56).

2.6.2 Non Native English Speakers or those with Limited English Proficiency

Health literacy is defined as the ability to read and comprehend health-related materials (57). 

While health literacy depends in part on individuals’ skills, it also depends on the complexity of 

health information and the way it is communicated (58). Only 12 percent of U.S. adults have 

high health literacy. Over a third of U.S. adults or approximately 77 million people would have 

difficulty with common health tasks, such as following directions on a prescription drug label or 

adhering to a childhood immunization schedule using a standard chart (58). Limited English 

proficiency rates are also prevalent among the poor, urban and minority populations (59). 

Studies of Limited English proficiency patients suggest that they are less likely to understand 

hospital discharge instructions or know essential information about diseases (60). 

Conceptually, health literacy affects patients’ ability to manage their health and influences their 

healthcare seeking behaviors. Patients with Limited English proficiency may find it difficult to 

understand, implement and adhere to their providers’ recommendations. This is particularly 

important for patients with chronic conditions. Limited English proficiency may also limit a 

patient’s ability to utilize emerging health technologies. Moreover, complex health information 

can overwhelm even individuals with proficient health literacy skills. Research has shown that 

health information often exceeds individuals’ health literacy capabilities (58). Recent years have 

seen an increase in awareness of the mismatch between patients’ skills and the health literacy 

demands that are placed on them. There is growing recognition that healthcare systems and 

professionals have a responsibility to accommodate and help improve patients’ understanding 

(58). 

Patients and caregivers with limited English proficiency are likely at increased risk of 

experiencing EHR usability or information comprehension problems, increased risk for 

inappropriate EHR utilization and less likely to achieve long term adoption of EHR systems. 
22

Limited English proficiency has, in the past been shown to be a contributor to healthcare 

disparities (14) and is also likely to be a contributor in the context of EHRs and electronic media 

among affected populations unless appropriate accommodations in the information architecture 

are included in the EHR design.

2.6.3 People Living with Disabilities

According to the 2000 U.S. census, an estimated 19% (about 1 in 5) people in the United States 

have a disability (roughly 50 million people). Approximately 5.2 million (8%) were between the 

ages of 5 and 20. Another 30.6 million (57%) were between the ages of 21 and 64 and the 

remaining 14.0 million (42%) were 65 and over. This makes people with disabilities the largest 

minority in the country. It includes people who have disabilities that vary from mild to severe, 

and it includes people with temporary as well as chronic disabilities. The size of this 

demography is surprising to many people because of a limiting conception of people with 

disabilities as those with visual manifestations of their disability (e.g., you can see white canes, 

service dogs, sign language, and wheelchairs). In fact, many people with disabilities have an 

invisible impairment undetectable by simply looking at them (e.g., those who are hard of 

hearing) (61). 

The Americans with Disabilities Act (ADA) of 1990 defines disability as the “inability to engage in 

any substantial gainful activity by reason of any medically determinable physical or mental 

impairment which can be expected to result in death or has lasted or can be expected to last for 

a continuous period of not less than 12 months” or “blindness” as defined as “central visual 

acuity of 20/200 or less in the better eye with the use of a correcting lens (62).”

The World Health Organization defines disabilities as follows: Disabilities is an umbrella term, 

covering impairments, activity limitations, and participation restrictions. An impairment is a 

problem in body function or structure; an activity limitation is a difficulty encountered by an 

individual in executing a task or action; while a participation restriction is a problem experienced 

by an individual in involvement in life situations. Thus disability is a complex phenomenon, 

reflecting an interaction between features of a person’s body and features of the society in 

which he or she lives (63). As such, several types of disabilities which could impact EHR 

utilization and the outcomes are recognized by the ADA. These impairments could significantly 

impact the patients’ and providers’ ability to appropriately use and/or benefit from EHRs thus 

exacerbating illness, disease and potentially, disparities too. These impairments and their 

relationship to EHRs and healthcare disparities will be discussed below.

2.6.3.1 Hearing Impairment

In 2008, approximately 35 million people (11.3% of U.S. population) were hearing impaired. This 

number is expected to increase to approximately 40 million by 2050 (64). There are two major 

dimensions that have a large impact on the experience of hearing impairment: age of onset and 

severity of hearing loss. Combined, these two dimensions create several categories of hearing 

impairment. Age of onset includes 2 sets of persons. One includes persons who were deaf at 

birth or very early in infancy. This person has been deprived of the opportunity to acquire normal 

speech and language patterns, thus the problem in communication is linguistic as well as aural. 

The other includes persons in whom hearing impairment occurs after the acquisition of normal 

speech and language patterns. Included in this group are those whose hearing loss is the result 

of injury, illness, or old age. Problem in communication is aural rather than linguistic (65).

Hearing loss may minimally impact on EHR usability or healthcare disparities except for audible 

alerts. If an EHR system relies on audible alerts to communicate important information to users, 
23

the needs of hearing impaired users would not be adequately accommodated placing them at 

increased risk of usability problems and poorer health outcomes.

2.6.3.2 Physical Disability and Motor Impairment

Physical or mobility impairment is defined as a limitation in independent, purposeful physical 

movement of the body or of one or more extremities. The alteration in a person's mobility may 

be either temporary, or more permanent. Most of the diseases and rehabilitative states involved 

in physical and mobility impairments do involve a degree of immobility. These are often 

associated with things such as leg fractures, strokes, morbid obesity, trauma, and Multiple 

Sclerosis. As well, mobility is related to changes in a person's body as they age. Loss in muscle 

strength and mass, less mobile and stiffer joints, as well as gait changes affect a person's 

balance and may significantly comprise their mobility. Mobility is crucial to the maintenance of 

independent living among seniors. If a person's mobility is restricted, it may affect their activities 

of daily living (66). The major types of motor impairment and their implications for EHR usability 

and healthcare disparities will be discussed in the following sections.

2.6.3.2.1 Fine Motor Control Impairment

Fine motor skills involve the coordination of small muscle movements which occur usually in 

coordination with the eyes. Loss of fine motor control can make viewing and using an EHR more 

difficult for seniors and thus less likely that they will use the EHR system appropriately or at all. 

Most commonly seen among seniors, limitations in fine motor control may also occur in the 

context of many other diseases and health conditions leading to an increased risk of visualperception problems. These may increase cognitive workload and limit information 

comprehension and understanding. It is also likely that a poorer user experience would inhibit 

EHR adoption. Research has demonstrated that improving the usability of systems by 

addressing fine motor control related to human factors issues will also allow all users to benefit 

from improved usability (9). 

2.6.3.2.2 Dexterity Limitations

When referring to fine motor skills of the hands and fingers, the term dexterity is commonly 

used. Loss of dexterity is a common problem which puts afflicted individuals at increased risk of 

EHR related disparities because it can reduce the usability of EHR systems. Dexterity limitations

therefore must be considered in EHR design if widespread usability is to be achieved

particularly among seniors who have the highest prevalence of these limitations. Arthritis is very 

common in the US population and is a major cause of mobility, fine motor and dexterity 

limitations. Another common dexterity related condition is Parkinson's Disease. Parkinson’s is a 

progressive condition affecting movements such as walking, talking, and writing (67). The four 

primary symptoms of Parkinson’s Disease are tremors (trembling in the hands, arms, legs, jaw 

and face), rigidity (stiffness of the limbs and trunk), slowness of movement (bradykinesia) and 

impaired balance and coordination (67). Parkinson’s Disease can also lead to cognitive and 

visual problems. Both arthritis and Parkinson’s are likely to cause difficulties with the use of 

mouse, other pointing devices, and keyboard in some sufferers (67).

2.6.3.3 Visual Impairment

2.6.3.3.1 The Blind

There is no single universally accepted definition of blindness. The Americans with Disabilities 

Act defines “blindness” as “central visual acuity of 20/200 or less in the better eye with the use 

of a correcting lens (62), while the Social Security Administration considers one blind if either 

the best eye cannot be corrected to better than 20/200, or the visual field is less than or equal to 
24

20 degrees with the aid of corrective lenses (62). The World Health Organization's (WHO) 

International Statistical Classification of Diseases and Related Health Problems (ICD-10) 

defines blindness as visual acuity of "less than 3/60 (0.05) or corresponding visual field loss in 

the better eye with best possible correction" (visual impairment categories 3, 4, and 5 in ICD10). This corresponds to loss of walk-about vision. Finally, the U.S. Bureau of the Census 

simplifies its definition into lay terms as unable to see regular-sized newsprint (65).

Almost all U.S. government agencies have adopted the use of medical measurements broken 

down into three categories of visual impairment, which are used to determine eligibility for 

services and financial compensation: 1. Totally blind; 2. Legally blind (20/200 or less visual 

acuity in the best corrected eye {20/200 visual acuity means that what a fully sighted person 

sees from 200 feet away, a person with 20/200 vision sees from 20 feet away}, and/or 20 

degrees or less in the visual field); 3. Partially sighted 20/70 visual acuity in the best corrected 

eye or 20 degrees or less in the visual field) (65). Individuals are legally blind when the best 

corrected central acuity is less than 20/200 (perfect visual acuity is 20/20) in your better eye, or 

your side vision is narrowed to 20 degrees or less in your better eye (68). People who are 

legally blind may still have some useful vision. Without appropriate EHR accommodation, visual 

problems will all lead to varying levels of visual-perception and associated cognitive and 

comprehension challenges among affected users, 

2.6.3.3.2 Low Vision (Legally Blind)

Low vision is a term that denotes a level of vision that is 20/70 or worse and cannot be fully 

corrected with conventional glasses. Low vision is not the same as blindness. Vision loss that 

may be severe enough to impede a person's ability to carry on everyday activities, but still 

allows some functionally useful sight. Low vision may be caused by eye conditions or diseases. 

Low vision may range from moderate impairment to near-total blindness. It cannot be fully 

corrected by eyeglasses, contact lenses, or surgery. However, a person with low vision may 

benefit from any of a variety of available optical devices, such as electronic magnifying glasses 

or eyeglass-mounted telescopes. In addition, special computer software developed for patients 

and providers with low vision can display the type in large size or read text aloud (69).

2.6.3.3.3 Poor Vision (Not Legally Blind)

Vision impairment (poor vision) is vision loss to such a degree as to qualify for additional 

support through a significant limitation of visual capability resulting from either disease, trauma, 

or congenital or degenerative conditions that cannot be corrected by glasses, medication, or 

surgery. However the level of impairment is not such that it constitutes legal blindness. Common 

conditions associated with visual impairments include albinism, astigmatism, cataract, 

glaucoma, hyperopia, myopia, nystagmus, retinitis pigmentosa, retrolental fibroplasia (RLF) and 

strabismus (70).

2.6.3.3.4 Color Deficiencies including Color Blindness

Physically, color vision is defined by the response of the cone cells in the retina of the eye, 

which transform light into a set of three color responses, very much as a digital camera filters 

light to produce red, green, and blue pixel values. Statistically, people with normal color vision 

all have the same “normal” cone response though in practice there is some variation. People 

with a color vision deficiency have one or more cone responses that deviate significantly from 

normal. Perceptually, color is organized into three dimensions: hue, lightness, and colorfulness. 

Hue corresponds to the name of the color, such as red, green, or purple. Lightness is the 

perceived lightness of a color. Colorfulness, sometimes called saturation or chroma, indicates 

how vivid the color is (71). Approximately 8% of Caucasian males have a difficulty perceiving 

reds and greens. Abnormal response to blues, purples, and yellows is very rare genetically (less 
25

than 1%), but affects men and women equally. However, it can be caused by head injury, 

disease, or medication, especially in older viewers (71).

According to the American Foundation for the Blind, color blindness is a vision problem in which 

a person has difficulty distinguishing certain colors—most commonly red and green, but 

sometimes blue and green or blue and yellow. Color blindness is not really a form of blindness. 

Common problems associated with different forms of color vision deficiency include a) green will 

appear lighter and more yellowish. Green on white may be impossible to see. Green and amber 

will be difficult to distinguish. b) Red colors will appear darker, making red on black especially 

difficult to see. Brown and gray will be difficult to distinguish. c) Some people have difficulty 

distinguishing red from green, though those only mildly affected can do so if the colors are 

sufficiently strong. A less appreciated, but potentially more common problem is distinguishing 

colors that differ only by the addition of red or green, such as blue vs. purple, yellow vs. orange, 

blue vs. cyan (aqua, teal), and gray vs. brown. Certain individuals have difficulty distinguishing 

blue from green and yellow from purple while others can see only two hues distinct from gray, 

plus lightness variations. Finally a small percentage of people see only shades of gray. Many of 

these have other visual problems as well (lack of acuity, sensitivity to light) (71).

2.6.3.4 Psychological (Cognitive) Disability

The word “cognitive” refers to the functions of the brain: knowing, thinking and learning. Some 

people are born with cognitive disabilities, such as autism or mental retardation, which can 

hinder development. Other cognitive disabilities can be caused by traumatic brain injury or 

stroke, while others can result from diseases that develop later in life, such as Alzheimer’s 

disease. 

These can be associated with a host of medical and health problems including poor medication 

adherence (missed doses, over/under dosing, mixing/confusing medications), errors in 

judgment, poor healthcare decision making and inappropriate behaviorism. Many cognitive 

disabilities have a base in physiological or biological processes within the individual, such as a 

genetic disorder or a traumatic brain injury. Other cognitive disabilities may be based in the 

chemistry or structure of the person's brain. Persons with more profound cognitive disabilities 

often need assistance with aspects of daily living. Persons with minor learning disabilities might 

be able to function adequately despite their disability, maybe, to the point where their disability 

is never diagnosed or noticed (72).

Cognitive disability puts affected EHR users at increased risk of poor outcomes and healthcare 

disparities because it is associated with several problems like reading comprehension, 

communication (verbal and written) impairment, confusion and inappropriate EHR utilization. 

Sometimes it is more useful to avoid the medical perspective of cognitive disability and view 

them from a functional perspective. A functional disability perspective focuses on the abilities

and challenges the person with a cognitive disability faces. Functional cognitive disabilities may 

involve problem-solving, attention, memory, and math, visual, reading, linguistic, and verbal 

comprehension (72).

Dyslexia is the most common form of language-based learning disability. Approximately fifteen 

to twenty percent of the population has some form of language-based learning disability. 

Dyslexia is primarily a reading disability, and there is evidence suggesting that dyslexia is a 

condition that is inherited. Dyslexia involves difficulty in single word decoding, often reflecting an 

insufficient phonological processing ability. This lack of ability is something that is many times 

unexpected in relation to the person's age and other cognitive and academic abilities. The 

person has not experienced another form of developmental disability, or sensory impairment. 

The person may have trouble with different forms of language, reading, and difficulty with 

spelling and writing as well (72).
26

Attention Deficit Hyperactivity Disorder (ADHD) is a medical condition affecting a person's ability 

to focus, sit still, and pay attention. Persons with ADHD may have difficulty in focusing on tasks 

or subjects, or act impulsively; they may also get into trouble. ADHD begins in childhood, but 

may not be diagnosed until the person reaches adolescence or even adulthood. Persons with 

ADHD may have difficulty with finishing assignments from school or tasks from home, jumping 

from one activity to another. They may lose things; forget things like homework or something 

they were supposed to do. They may have difficulty with following instructions, or following 

through with tasks they have been assigned. The person may make careless mistakes, or have 

difficulty paying attention to details. Persons with ADHD may have trouble organizing activities, 

or tasks, and may interrupt other people. They may fidget, feel restless, or talk excessively. 

Other major categories of functional cognitive disabilities include deficits or difficulties with 

memory, problem-solving, attention, reading, linguistic, and verbal comprehension, math 

comprehension and visual comprehension (72).

The main reason why these functional disabilities are more useful when considering EHR 

accessibility is that they are more directly related to the concerns of EHR developers. Telling a 

developer that some people have autism is not very meaningful unless the developer knows 

what kinds of barriers a person with autism might face. On the other hand, telling a developer 

that some people have difficulties comprehending math, provides the developer with a 

framework for addressing this type of audience (73).

Cognitive disability entails a substantial limitation in one's capacity to think, including 

conceptualizing, planning, sequencing thoughts and actions, remembering, interpreting subtle 

social cues, and understanding numbers and symbols. Cognitive disabilities include intellectual 

disabilities and can also stem from brain injury, Alzheimer's Disease and other dementias, 

severe and persistent mental illness, and, in some cases, stroke (73).

The definition used most often in the United States is that intellectual disability is a disability that 

occurs before age 18. It is characterized by significant limitations in intellectual functioning and 

adaptive behavior as expressed in conceptual, social and practical adaptive skills. Intellectual 

disabilities are also known as developmental delay or mental retardation. Intellectual 

functioning, also called intelligence, refers to general mental capacity, such as learning, 

reasoning, problem solving, etc. One criterion to measure intellectual functioning is an IQ test. 

Generally, an IQ test score of around 70 or as high as 75 indicates a limitation in intellectual 

functioning. But in defining and assessing intellectual disability, professionals must take 

additional factors into account, such as the community environment typical of the individual’s 

peers and culture. Professionals should also consider linguistic diversity and cultural differences 

in the way people communicate, move, and behave (73). Finally, assessments must also 

assume that limitations in individuals often coexist with strengths, and that a person’s level of 

life functioning will improve if appropriate personalized supports are provided over a sustained 

period (73).

2.6.4 Seniors and the Elderly

In 2000, there were 281.4 million people in the United States. Approximately 72 million (26 %) 

were under age 18, 174.1 million (62%) were age 18 to 64 and 35.0 million (12%) were over the 

age of 65. The median age of the U.S. population increased from 32.9 in 1990 to 35.3 in 2000. 

Also in 2000, the two largest 5-year age groups were 35-to-39 year olds with 22.7 million people 

(8.1% of the total population) and 40-to-44 year olds with 22.4 million people (8.0% of the 

population). People in these two age groups were primarily born during the post-World War II 

“Baby Boom” (those born from 1946 through 1964). In Census 2000, the baby boom cohort was 

age 36 to 54 and represented 28 percent of the total U.S. population (74).
27

In terms of rate of growth the 50-to-54 year old age group experienced a 55% growth in 

population over the past decade while 45-to-49 age group experienced a 45% increase. The 

baby-boom cohort entered these two age groups during the past decade. The third fastestgrowing group in the past decade was 90-to-94-year olds, which increased by 45%. On the 

other hand four age groups declined over the past decade. These include the 25-to-29 year olds 

(9% decrease), 30-to-34 year olds (6% decrease), 65-to-69 year olds (6% decrease), and 20-to24 year olds (0.3% decrease). The number of people in the younger age groups, especially 

those aged 25 to 34, fell as the baby boom cohort aged into older age groups. The decline in 

65-to-69 year olds is associated with a relatively low number of births during the early 1930s 

(74).

Seniors are a target population at increased risk for experiencing healthcare disparities with 

EHR use because increasing age is often accompanied by increasing levels of human factors 

challenges that may impact EHR usability. The commonly accepted limitations that often arise 

during the normal aging process, which may impact EHR usability, include vision decline, 

hearing loss, motor skill diminishment and cognitive effects. (See section 2.6.3) In addition the 

aging process can often result in elderly people experiencing multiple functional limitations. 

Each of these major areas will be briefly described below.

2.6.4.1 Age-Related Vision Decline 

A variety of vision changes may occur with aging. These include decreasing ability to focus on 

near tasks, including a computer screen and color perception and sensitivity problems causing 

less violet light to be registered (67). This has the effect of making it easier to see red and 

yellows than blues and greens and often making darker blues and black indistinguishable. In 

addition seniors often have pupil shrinkage resulting in the need for more light and a diminished 

capacity to adjust to changing light levels (67). They also suffer contrast sensitivity loss. In fact, 

from the age of 40, contrast sensitivity at higher spatial frequencies starts to decline until at the 

age of 80 when it has been shown to be reduced by up to 83% (67). Reduction in visual field is 

another vision problem associated with aging that can seriously affect vision. Visual field loss 

can be caused by Cataracts which is a treatable disease resulting in a clouding of the clear lens 

in the eye, causing blurred vision and glare sensitivity (67). Visual field loss may also be caused 

by what is known as Age-related Macular Degeneration (AMD). AMD is incurable and results in 

central vision deterioration and an inability to see fine detail and distinguish color possibly 

combined with a sensitivity to glare (67).

2.6.4.2 Age-Related Hearing Loss

In terms of hearing loss, seniors often notice a gradual age-related reduction and the increasing 

inability to hear high pitched sounds. It is estimated that around the age of 50 the proportion of 

deaf people begins to increase sharply and 55% of people over 60 are deaf or hard of hearing 

(67).

2.6.4.3 Age-Related Cognitive Decline

The ability to encode new memories of events or facts and working memory show declines in 

both cross-sectional and longitudinal studies (75). Studies comparing the effects of aging on 

episodic memory, semantic memory, short-term memory and priming find that episodic memory 

is especially impaired in normal aging (76). These deficits may be related to impairments seen 

in the ability to refresh recently processed information (77). In addition, even when equated in 

memory for a particular item or fact, older adults tend to be worse at remembering the source of 

their information (78), a deficit that may be related to declines in the ability to bind information 

together in memory (79). It has also been suggested that situation awareness may be relevant 
28

to cognitive aging, affecting older adults’ perception and comprehension of their environment 

(80).

While most older adults may not suffer from dementia or Alzheimer’s Disease, many do suffer 

Mild Cognitive Impairment (MCI) or subjective memory loss (67). The issues associated with 

MCI include trouble remembering the names of people, trouble remembering the flow of a 

conversation and an increased tendency to misplace things. All these complaints are likely to 

also impact on the use of EHRs (67). 

2.6.5 Racial and Ethnic Minorities

Racial and ethnic minorities have been shown to be at increased risk for Healthcare disparities. 

Despite many differences, as a group they also share some characteristics that may have 

human factors implications for the design, adoption and utilization of EHR systems. For 

example, racial and ethnic minorities are more likely to speak a non-English language as their 

primary language used in the home. As such, understanding even simple English words and 

phrases may prove challenging. They are also at higher risk of having limited English 

proficiency. They are also more likely to receive care from a healthcare safety net provider 

working in a low resource setting with a user context significantly different from that of another 

provider working in an alternate setting. Finally, racial and ethnic minorities are more likely to 

have mental models of health and illness that differ from those of a healthcare provider born and 

trained in the United States. These other models include beliefs that health/illness is ordained 

by God, and choices about healthcare service utilization are made in a communal fashion only 

after discussion with other respected members of the group. Attempting to facilitate patient 

healthcare decisions via use of the EHR may lead to patients intentionally providing erroneous 

or misleading information, failing to utilize or underutilizing the EHR system because of lack of 

trust or in an effort to avoid culturally difficult situations. All of these could potentially impact 

patient outcomes among this user group. 
29

3 EHR Technical Considerations of Healthcare Disparities

The following sections present an overview of those steps in the EHR design process that 

potentially impact healthcare disparities. Current vendor practices indicate that EHR design and 

development strategies only minimally consider formal Human Factors Engineering (HFE) and 

ergonomics design principles if at all (7). As such, there may be an under appreciation of the 

potential magnitude of the impact of design flaws on usability and the context of use that could 

lead to healthcare disparities. 

3.1.1 The EHR Development Life Cycle

The EHR design process shall be an iterative process that involves: 1) planning and 

development of EHR requirements and specifications; 2) designing and building the EHR to 

planned specifications; and 3) review and testing of the EHR prototype. An optimal EHR is the 

product of multiple development, design, prototyping, review and evaluation iterations. In 

addition, early involvement of users in development is an absolute requirement to the 

development of high quality and usable EHRs. 

In terms of healthcare disparities, there is no evidence that involvement of a reasonable set of 

representative users (providers, patients, caregivers) from disparity populations are consistently 

involved in all phases of the design process. As such, current EHR designs may not adequately 

meet the needs, provide optimal user experiences or be appropriately usable by all providers 

(aging providers, providers with disabilities) caring for patients at increased risk of disparities or 

among patients and caregivers from disparity populations. The EHR design and development 

considerations most likely to impact the risk of healthcare disparities will be briefly outlined 

below (81). 

3.1.1.1 EHR Planning

The EHR planning process consists of preparing a complete and comprehensive design and 

development plan for all intended EHR users. The plan is based on the articulation of clear 

design requirements for each type of user, all user tasks and each type of user environment. 

Essential EHR design requirements that may impact healthcare disparities include task 

analysis, user experience requirements, EHR interface design requirements, user living and 

working condition (user context) and cultural requirements (81). Failure to adequately consider 

these design elements could lead to a reliance on inappropriate or incorrect design assumptions 

regarding a given type of EHR user or user context.

3.1.1.1.1 Task Analysis

A task analysis is the collection and analysis of information about the intended users of the 

system and the tasks that they will perform. The design requirements should be based on 

comprehensive task analyses. An overall concept should be developed of the users (providers, 

support staff, patients' caregivers, etc.), their needs and their roles in managing health and 

healthcare tasks. The effect of the EHR on the existing tasks of individual users should be 

analyzed. This should include a consideration of any potential changes that may result from the 

initial combined use of electronic and paper-based systems. The effects of the EHR system on 

user communications should be evaluated. Tasks should be analyzed and used as an input to 

design. Tasks associated with failure and backup should be identified to define the requirement 

for indicating malfunctions. The task of smoothly transitioning from a paper based system to an 

EHR system and back to a back-up paper system, if needed, in the event of system failure, all 

should be explicitly analyzed and addressed (82).
30

EHRs should be designed to take account of the people who will use them. Therefore, all 

relevant user groups should be identified. Constructing systems based on an inappropriate or 

incomplete understanding of user needs is one of the major sources of systems failure. It is 

likely also to be a potential contributor to the development of healthcare disparities. The extent 

to which products are usable and accessible depends on the context of use. The characteristics 

of the patients and providers, tasks and environment in which the EHRs will be used, comprise 

the context of use (17). The context of use is a major source of information for establishing 

requirements and an essential input to the design process (17). Provider, patient and caregiver 

user contexts will not always be the same. Patient and provider contexts may be the same 

during a clinical encounter; however, it is likely that, in the future, patients will increasingly 

interact with their providers and EHRs in both synchronous (in real time) and asynchronous (via 

messaging) fashion in the context of both face to face and remote clinical encounters. Given this 

reality, the steps required to accomplish a given task or even the required tasks needed to 

accomplish a given function may themselves differ depending on the context in which the 

patient may be using (e.g., home) vs. that in which the provider may be using (e.g., clinic or 

Emergency Department). Assumptions about patient and caregiver user contexts based on 

provider user contexts will likely lead to inadequate designs. In addition, the user contexts 

between different types of providers (safety net providers, academic clinicians, rural solo 

practitioners) may be sufficiently different that inadequate attention to this issue could lead to 

poor designs for one or more types of providers. As can be seen, robust task analysis among all 

intended users is a critical determinant of usable EHRs that do not contribute to healthcare 

disparities. (82)

Task analyses should also identify the implications of working conditions requiring competing 

demands on attention and mental workload of users. The basis for these analyses can be found 

in Multiple Resource Theory (83). It is imperative that designers have an explicit understanding 

of the EHR user contexts in order to be able to accurately distinguish compatible tasks (those 

which can be safely performed simultaneously) from incompatible tasks (those which carry a 

higher risk of error, data loss or other harm, if performed simultaneously). With this knowledge, 

EHR system architects can better design systems that support provider or patient focal tasks 

(the task judged to be most important) without causing inappropriate task incompatibility or 

forcing an EHR user to focus attention on a less important task (distracter) because of system 

design defects (83). 

Finally, task analyses should also provide a basis for determining training requirements for all 

EHR users (82). The training program should address the role of the providers and patients to 

assure that they remain in control of the EHR system. The knowledge, skills, and abilities that 

patients and providers will require to interact successfully with the EHR should be specified by 

the designers (82). Computer/technology literacy, computer familiarity and technology related 

user anxiety have all been shown to be health IT usability barriers among the elderly, chronically 

ill, disabled and medically underserved patients (84;85). On the other hand, computer training, 

technology support and lost productivity due to prolonged training have all been implicated as 

usability and adoption barriers among providers, especially those caring for the nation’s most 

vulnerable patients (86;87).

3.1.1.1.2 User Experience requirements

User experience is defined as a person's perceptions and responses resulting from the use 

and/or anticipated use of a product, system or service (17). Usability can be seen as one aspect 

of the total user experience. On the other hand, poor user experience with a technology may 

inhibit usability and adoption. The EHR user experience then, is a consequence of several 

factors including the presentation, functionality, system performance, interactive behavior, and 

assistive capabilities of the system. It has been shown to impact beliefs about ease of use and 
31

perceived usefulness (88). Minority providers, solo practitioners and providers caring for 

underserved populations often report lack of perceived usefulness of EHRs as a significant 

barrier to adoption and utilization. Thus, among those providers most likely to care for patients

from disparity populations, lack of attention to user experience when designing EHRs could 

facilitate EHR adoption disparities. To effectively reduce healthcare disparities it may prove 

important to determine the user experience requirements for patients and caregivers. If EHRs 

are designed to provide optimal user experience for the providers, they may fail to provide the 

same for patients and contribute to poor patient utilization of EHRs despite provider utilization. 

Important considerations that may impact user experience will be briefly discussed below.

3.1.1.1.3 User Living Environment (Context) Requirements

The extent to which EHRs are usable and accessible depends in part on the physical 

environment in which they will be used. The relevant characteristics of the environment that 

impact usability must be described for each user context. Important physical attributes include 

issues such as thermal conditions, lighting, spatial layout and furniture. Currently, there is 

substantial ongoing effort to understand these issues in the hospital, clinic or practice 

environment. 

For example, it is well known that among individuals living in rural America, access to primary 

care is a significant challenge. Approximately one quarter of the U.S. population lives in rural 

America yet only 10% of all physicians live and practice in these areas (89). The obstacles 

faced by healthcare providers and patients in rural areas are, at times, vastly different than 

those in other areas. Rural Americans face a combination of factors that place them at 

increased risk of experiencing disparities in healthcare. Economic factors, cultural and social 

differences, educational shortcomings and the sheer isolation of living in remote rural areas all 

conspire to impede rural Americans in their struggle to lead a normal, healthy life as compared 

to those living in other environments (90).

In terms of EHRs and usability, EHR use is less common in rural locations and in small 

practices where access to broadband services are limited (91). The home and living 

environments of rural Americans likely present other important usability challenges that must be 

addressed. For similar reasons, the EHR accessibility, usability, lighting, humidity, safety and 

privacy issues associated with urban inner city and low income housing must be taken into 

consideration when developing EHRs for use by patients living in these settings.

3.1.1.1.4 Cultural Requirements

Historically, ergonomics as a discipline was started in North America and Western Europe and 

produced findings and data that apply primarily and best to Western customs, habits and ways 

of life (92). Increasingly though, culturally related problems with the interaction between users 

and technology are being attributed to lack of consideration of human factors (92).

Several aspects of culture have been evaluated by human factors and ergonomics experts and 

found to be of importance to interface design and usability. This field of study, called Cultural 

Ergonomics (CE), has mainly focused on applications in aviation and international user 

interfaces. CE does not argue that biological differences associated with membership in specific 

cultural groups accounts for differences in usability or behavior, but rather proposes that culture 

is a persistent situational phenomenon that is manifested through persistent patterns of 

interaction with the environment. These persistent patterns in behavior directly extend from 

beliefs, values, and mental models. Thus, cultural influences are environmental, and therefore, 

situation-based (93). 
32

Given the substantial racial and ethnic demographic shifts occurring in the US, the implications 

of existing differences in health paradigms or mental models of health across patient 

populations will, at a minimum, require EHR accommodations based on appropriate use case 

data. In “Western” countries, the allopathic or “orthodox” medical model is the dominant health 

paradigm. However, there are also two other models of Western healthcare, the social model 

and the psychological model. These models have different assumptions about the nature of 

illness and wellness and differences of approach to the maintenance of good health and the 

treatment of illness. They also often use different terms for the same health concept (e.g. 

“problems” in the medical model and “issues” in the social model). However, differences 

between Western and non-Western health models are generally greater than those between the 

three Western models (94). 

Oriental medicine (e.g. Chinese medicine) and Ayurvedic medicine, collectively often called 

“alternative” or “complementary” medicine in Western countries, are fundamentally different 

from Western orthodox medicine. The practitioners of these different health models not only use 

different terms for the same entity but sometimes also use the same term to express different 

concepts. For example, the terms “inflammation” and “elevated calcium” have quite different 

meanings for Western and some alternative/complementary practitioners (94). 

A single EHR, across different health paradigms, could be very beneficial for the holistic care of 

patients seeking care from practitioners of different health models (estimated to be more than 

50% of the population in many countries). However, it could also be potentially dangerous or 

even life-threatening for a patient, unless different technical assumptions and different meanings 

for the same terms are recognized and incorporated into the EHR (94). There is little, if any 

experience as yet, in using a single EHR across different health paradigms but there are 

techniques available in the evolving model-based EHR standards to assist in dealing with these 

challenges. For example, the use of “folders” within the EHR is one way to segregate different 

types of EHR content. Also different folders may be used for acute hospital care, primary care, 

mental health, and “alternative” care practitioners such as herbalists and naturopaths. The use 

of archetypes for clinical content and distinct domain-specific term sets to underpin the 

archetypes will also assist in avoiding problems due to different healthcare paradigms within a 

single EHR (94).

3.1.1.1.5 EHR Human-Computer Interface Requirements 

Among providers, the organization and display of information is essential to effectively support 

clinical care, maximizing usability and reducing the potential for user error (95). The EHR user 

interface, through which the care team enters and retrieves patient information, care guidelines 

and medical evidence must be highly efficient, intuitive, and responsive to varying clinical 

information needs, to adequately support the practice of medicine (95). Because EHRs will also 

support doctor-patient communication, patient education and enhance patient engagement in 

disease management, the interface must also support the needs of patients and caregivers. 

There are at least 2 key factors that can impact interface requirements that may affect

healthcare disparities with the use of EHRs. These are the role of disability (See section 2.6.3)

and culture (See Section 2.7.1.3) on the information architecture. It is likely that these factors 

will predominately affect patient and caregiver EHR usability. However, to the extent that 

providers are themselves becoming an increasingly diverse population, these factors may also 

have some impact on provider EHR usability. The existing research and knowledge regarding 

the role of culture specifically on interface design and usability will be outlined below. 

Almost 3 decades ago cultural differences in everything from the legibility of alphabetic 

characters (96), to working posture were described and explored for the implications of these 

differences on design. More recently, it has been shown that cultural factors influence 
33

appropriate mappings between controls and displays (97), colors and concepts (98) and icons 

and concepts (99). For example, while 100% of Americans associated the concept stop with the 

color red, only 48.5% of Chinese agreed with this mapping. Additional work in this domain has 

shown that there are cultural differences in the appropriate navigational structure (100;101) and 

the type of overarching metaphor used in computer displays (102). In the 1990s, the concept of 

“hidden cultural assumptions” (103) in health information technology was put forth which 

suggested that although designers often believe their creations are culturally neutral, in 

actuality, technologies embody cultural assumptions that may not always be appropriate for the 

intended user.

EHR user characteristics which exhibit cultural variability can be grouped into two basic 

categories. These include physical characteristics and visual/cognitive characteristics. Physical 

characteristics or anthropometry, from an engineering standpoint, is concerned with integrating 

physical characteristics into the development of engineering design standards (92) However, 

applying American anthropometric design standards without any adjustment to other 

populations of the world may cause significant problems. In general, an interface design which

is suitable to fit 95% of Americans, fits 90% of Germans, 80% of the French population, 65% of 

Indian population, 45% of the Japanese, 25% of Thais and only 10% of Vietnamese (92). The 

implications of such variations for technology design problems and the degree of required 

changes and/or adjustments that may be needed are significant. Consideration has to be given 

not only to display height, but also sitting statures, working postures, and leg length in 

proportion to height. It has been convincingly shown that simply scaling up or down to fit these 

anthropometric differences simply does not work (92). 

Studies of perceptual processes have shown that perception has cultural characteristics with 

regard to interpretation of observations and data. For example, Nepalese individuals have 

significant difficulty reading and interpreting maps and spatially oriented diagrams while 

Vietnamese individuals have difficulty understanding and interpreting technical drawings (92). 

Research evaluating preferences in direction-of-movement tendencies found that strong 

direction of movement preferences exist in Western culture (read from left to right, off = turning 

dials left to right, on = turning dials right to left, etc). Subjects of individuals of non-western 

ethnicity and nationality indicate that these preferences are not universally held and are subject 

to local exposure and education (92). 

The mental processes of different cultures may also impact usability of EHRs. This is because 

differences in performance levels of individuals of different cultural backgrounds is not usually 

caused by differences in cognitive capabilities of the individuals rather the primary factors 

responsible for observed differences are individuals’ cognitive complexity, information 

processing behavior, and psychomotor skill (92). The potential for developing complex cognitive 

abilities exists; it merely needs to be stimulated and exercised through application of appropriate 

training procedures. Cognitive characteristics and perceptual processes, therefore, are culturally 

influenced. Awareness of the potential influence on the performance of a particular task or 

usability of a given tool is necessary and should be made a major consideration in determining 

the human-computer interface requirements for future EHRs.

Finally, objective evidence exists suggesting a link between culture and usability (104). Some 

cultural dimensions including power distance, individualism versus collectivism, and uncertainty 

avoidance may impact usability and may be affected by user interface design (104). Power 

distance measures the extent to which the less powerful members of a group accept and expect 

that power is distributed unequally. Low power distance scores reflect less acceptance of the 

unequal distribution of power, while higher scores reflect greater acceptance of unequal 

distribution of power within one’s culture (104). Individualism and collectivism focuses on the 

relationship between the individual and groups. Highly individualistic cultures (European) 
34

believe that the individual is the most important unit while highly collectivistic cultures (Asian, 

African-American) believe that the group is the most important unit. Low scores indicate strong 

collectivism while high scores suggest strong individualism within a given culture (104). Finally, 

Uncertainty Avoidance (UA) is the extent to which a culture feels threatened or anxious about 

ambiguity and how hard individuals will work to avoid it. UA focuses on how cultures adapt to 

change and cope with uncertainty. As such, low UA cultures tend to respond well to ambiguity 

and uncertainty while high UA cultures do not (104).

Patients who exhibit high uncertainty avoidance may experience greater frustration with certain 

interface designs (104). In addition, individuals from cultures with low power distance indicators 

(e.g., people more accepting of uneven power distribution) may be more likely to score higher 

on usability testing of an interface than individuals from cultures with high power distance 

indicators (104).

3.1.2 The Potential of EHR Technical Design Issues to Impact Healthcare Disparities

As can be seen from the above discussion, there are potentially many opportunities during the 

EHR design and development lifecycle, where oversights, flawed designs or otherwise poor 

designs, based on faulty assumptions, lack of representative data or inadequate information 

architecture could contribute to reductions in EHR access, usability or adoption and in turn 

increase the risk of poor outcomes and healthcare disparities among at risk patient populations. 
35

4 Technical Guidance and Recommendations

There is great need for federal coordination and integration across multiple agencies. 

Coordination must be built on explicit plans and strategies (105). One critical area of needed 

federal leadership is in the area of technical guidelines and standards that will help ensure 

broad accessibility and usability and thereby reduce the possibility of creating or exacerbating 

healthcare disparities with the roll out, adoption and utilization of EHRs and other emerging 

health IT products.

Because improvements in accessibility and usability tend to benefit everyone, addressing 

human factors challenges will likely benefit all EHR users. Improvements in EHR accessibility 

and usability will contribute to higher adoption rates among providers. Increasing meaningful 

use by providers combined with improving patient engagement in their healthcare through 

EHRs, will lead to improvements in healthcare quality and health outcomes. In addition, among 

patients with disabilities, those with limited English proficiency, lower socio demographic groups,

and seniors, these improvements will likely also contribute to reductions in healthcare 

disparities. The following is a discussion of specific guidelines and recommendations that may 

be taken to reduce the risk of healthcare disparities on healthcare delivery with the adoption of 

EHRs. 

4.1 EHR Design and Development Guidelines

Several design enhancements may significantly reduce the likelihood of introducing or 

exacerbating healthcare disparities with the adoption of EHRs. Generally, these 

recommendations focus on equipping the EHR design team with the necessary information 

needed to understand potential healthcare disparities challenges related to provider and patient 

use of the EHR. These recommendations also focus on ensuring that this information is then 

used to improve the iterative design process and ultimately make the appropriate product 

enhancements.

4.1.1 Conduct Comprehensive Formative and Summative Testing with a Reasonable Set 

of Representative End Users

To help ensure EHR accessibility and usability, it is imperative that developmental testing 

involve those who are likely to be using the system. While current EHR systems are designed 

primarily to facilitate medical practice by healthcare practitioners, they are intended to also be 

used to enhance physician-patient communication and engagement primarily in the context of a 

clinical encounter. As such, the needs of the patients and caregivers who will be interacting with 

the provider must be taken into consideration, if the information provided to the patient is to be 

understood and then used by the patient in shared decision making and disease selfmanagement. Patients, consumers and caregivers, like providers, have a spectrum of physical, 

cognitive and other needs that can significantly affect physician-patient communication, 

understanding, motivation and ultimately outcomes. A large body of human factors research has 

been done regarding human-computer interactions and accommodations. Many technical 

accommodations have been developed, tested and validated as effective in addressing potential 

human factors needs. This body of knowledge should be integrated into the design of current 

and emerging EHR systems, to ensure the widest possible accessibility and usability and to 

ensure the safe, effective and error free interactions with EHRs by the end users. The 

importance of considering the needs of providers must not be ignored nor underappreciated. 
36

However, considering only the needs of the provider will tend to minimize the physician’s ability 

to provide consistent, high quality, patient-centered care and improve patient health outcomes.

4.1.2 Report Results of the Tests in Common Industry Format (CIF) for EHR Usability Test 

Reports

Usability of EHR systems is a key factor in predicting successful deployment. EHR system 

developers must subject EHRs to usability testing at various stages in a product’s development

cycle. Testing should involve (1) test participants who are representative of the target population 

of EHR users, (2) representative tasks, and (3) measures of efficiency, effectiveness and 

subjective satisfaction. The Common Industry Format (CIF) is intended for reporting the results 

of usability testing (8).

Given the plethora of EHR products and vendors, CIF is valuable because it standardizes the 

types of information that should be captured regarding testing with users. The major variables 

include user demographics, task descriptions, context of the test, including the equipment used, 

the environment in which the test is conducted and the protocol by which the subjects and the 

test administrator(s) interact, as well as the particular metrics chosen to code the findings of the 

study. The CIF is intended to replace proprietary formats employed by EHR vendors, 

developers and purchasers that perform usability testing. The advantages of using a 

standardized reporting format include (1) a reduction in training time for usability staff since an 

individual only needs to learn to use one and (2) enhanced potential for increased 

communication between vendors and purchasing organizations since readers of CIF-compliant 

reports will share a common language and expectations.

Another purpose of the CIF is to facilitate incorporation of usability testing into the procurement 

decision-making process for EHR systems so that it is easier to judge whether a product meets 

the usability goals. It provides a common format to report the methods and results of usability 

tests to customer organizations (8).

CIF should be used by usability professionals within supplier organizations to generate reports 

that can be used by customer organizations. The CIF is also meant to be used by customer 

organizations to verify that a particular report is CIF-compliant. As such, the usability test report 

itself is intended for two types of readers: 1) Usability professionals in customer organizations 

who are evaluating both the technical merit of usability tests and the usability of the products; 

and 2) Other technical professionals and managers who are using the test results to make 

business decisions. The CIF may also be used within a single organization if a formal report of a 

summative usability test needs to be generated. In this case additional material such as a list of 

detailed findings may be included (8).

4.1.3 Accommodate as Many EHR Users as Possible Using Universal Design Principles

To ensure that as many users as possible including safety net providers practicing in under 

resourced settings and patients from disparities populations are able to safely and effectively 

use emerging EHR systems, a universal design strategy should be adopted. Universal design 

principles incorporate user-centered design, universal usability and universal accessibility 

principles to bring attention to both the potential EHR user challenges and accommodation 

solutions that might be otherwise overlooked. Accommodating a broader spectrum of users and 

user contexts will require designers to consider a wide range of designs. Many of the design 

accommodations can be incorporated without significant impact on developmental time or 

expense. Once completed, these improvements often lead to innovations that benefit all users 

(9). These features should include Graphic User Interface (GUI) elements that will support 

system novice users and at the same time will offer shortcuts to expert and advanced system 

users. 
37

4.1.4 Include Disparities Oriented Use Cases as Part of the EHR Design and Development 

Process

EHR developers should use disparities oriented use case scenarios and user contexts to test 

how well their systems support providers caring for disparity populations. Incorporating such 

focused use-cases into the formative EHR development process could help developers 

overcome current expertise shortages and barriers to adoption and use by these providers.

Examples of disparities oriented use cases include:

1) Safety net provider use case. Developing and applying use cases involving 

common tasks specific to clinical practice in safety net contexts will be a key to 

elucidating unrecognized user requirements.

2) Adult caregiver of a senior relative use case. In many families, adult children 

caring for elderly parents, is becoming increasingly common. This may be even more 

likely among patients from disparity populations who may lack resources to provide 

alternate care arrangements for their aging relative. The cognitive and physical 

demands and stress of care giving combined with childrearing, homemaking and 

also additional employment may create human factors challenges for the safe and 

effective use of EHRs. In other words, the consideration of these broader patient 

user contexts, may be as critical for understanding EHR usability by patients as 

understanding clinical workflows in the hospital is for understanding provider EHR 

usability

3) Patient/caregiver with limited English proficiency use case. Providing care to 

patients with limited English proficiency creates challenges for all involved parties. 

This is no less true in the context of EHR mediated care. If patients cannot 

understand their English speaking healthcare providers they are not likely to 

understand their English language based EHRs. This is not surprising. What is less 

clear is what, if anything, these patients may do to overcome deficiencies of 

understanding, especially in the absence of appropriate accommodations when 

attempting to use, or access an EHR. Misunderstandings or confusion caused by a 

poorly designed EHR, in the context of marginal English proficiency may prove more 

challenging and more difficult to even detect than complete inability to use the 

available system unless these types of use cases are employed. Use plain language 

instructions to accommodate these user contingents. 

4) EHR use in the context of cross cultural or communications barriers use case. 

In some cultures, major decision making, is considered a family or at least a 

combined activity between a husband and a wife. However, informed consent and 

access to EHR information is currently considered largely from the Western 

perspective (i.e. single users and individual rights). Usability, user experience and 

satisfaction implications with the use of such an EHR are not likely to be optimal. 

There may be design accommodations that could help address the challenges 

created by these cultural differences.
38

4.2 EHR Evaluation Guidelines

4.2.1 Require Documentation of Formative and Summative Testing with a Reasonable Set 

of Representative Target Users as a Prerequisite for EHR Evaluation

To ensure that appropriate formative and summative testing is indeed occurring, it is 

recommended that periodic documentation be provided as a part of the EHR evaluation and 

reevaluation process.

4.2.2 Require Documentation of Product Features Designed to Increase Usability and 

Accessibility or Documentation of a Lack of Need for any Accommodation among 

a Reasonable Set of Target Users

To ensure that vendors are making appropriate design enhancements specifically for the 

purpose of improving identified limitations among target users, it is recommended that 

documentation of included product features be provided as part of EHR evaluation and 

reevaluation process.

4.2.3 Require the Development of EHR Operation, Safety, Customer Support and 

Educational Materials that are Culturally and Linguistically Appropriate for a 

Reasonable Set of Representative Target Users as a Prerequisite for EHR

Evaluation Process 

Writing clear EHR related system messages and instructional and educational materials is 

critically important as an increasing variety of users adopts EHRs. The following specific 

recommendations are made for instructional materials for both paper and electronic formats 

(10). These should not be viewed as an exhaustive nor comprehensive set of 

recommendations. Rather these can be considered as a starting point for the development of 

more effective and usable EHR instructional materials.

EHR Operation and Safety Instructions Development Recommendations

1) Put instructions where (at specific point on the screen) they are needed – not all 

together at the top of the page. Instructions must come "just in time" – when EHR 

users need them – at the beginning of the section where they are relevant. Having all the 

instructions at the beginning, poses a heavy burden on EHR user’s memory. People 

tend to pay attention only if the instructions seem relevant to their current needs. They 

may not read instructions that do not apply at the moment they are reading them. The 

more there is to read in one place, the more likely it is that many providers and clinicians 

will just skip the instructions. When instructions come "just in time," there are fewer to 

give at any one place (10).

2) Put instructions above/before they are needed – not after Instructions for specific 

parts of an EHR system must come just before the provider has to act. This guideline 

does not conflict with the previous one. Clinicians need instructions at the place in the 

EHR where the instruction is relevant. And they need those instructions just before and 

not after the options the instructions relate to. This is necessary because people read 

and act in the order in which information comes to them. They do not skip over the 

action part to look for instructions (10).

3) Put instructions in logical order first task, first; last task, last. Instructions for 

specific parts of an EHR must come in the order that providers and patients need them 

because they make more sense if they come in the order in which they will be used. 

Also, if providers have to go back to look for what to do in case of a problem, they will 

likely look to the end of a list of instructions (10).
39

4) Put warnings about consequences before – not after – the provider is likely to act. 

Providers and clinical staff must learn about the potential negative consequences of an 

action before the instruction to take the necessary action since people often act as soon 

as they see an instruction. If they act before reading the warning, they will not be able to 

heed the warning (10).

5) Do not highlight the action option until providers have been given all available 

options. Providers must be given all available options to choose from before they are 

given the signal to make the choice. This is because people are drawn to the first and 

brightest message they see. Flashing words or buttons are very eye-catching even when 

they are in peripheral vision. If a bright or flashing message suggests that it is time to 

take an action, many clinicians will be distracted and not realize that they have not yet 

looked at the rest of the screen (10).

6) The order of buttons must match the order of the instructions. The order of choices 

in the instructions and the order of the buttons that relate to those choices must match. 

Clinical staff may assume that the order is the same and inconsistency between the 

instruction and the buttons may cause some clinicians to make errors (10).

7) Start each instruction on a new line. Each instruction must start on a new line. 

Different instructions must not be combined together in a single paragraph. If each 

instruction starts on its own line, providers and clinical staff will be less likely to miss an 

instruction, can more easily see that there are multiple situations and multiple 

instructions and will more easily find an instruction if they come back to look for it. Under 

the time stress, busy clinicians often scan rather than read. Instructions on separate 

lines are easier to scan than instructions in a paragraph (10).

8) Write directly to the clinician. Instructions must be in the imperative (i.e., "Do this...").

Statements of fact or law must not replace instructions. Instructions tell people what to 

do. People are more likely to act appropriately when they read instructions than when 

they read statements about facts. Also, sentences with imperative verbs are in the active 

voice. English sentences can be in either active voice or passive voice. Passive 

sentences are more difficult to understand than active sentences because the pieces of 

a passive sentence are not in logical order from the clinicians’ point of view (10).

9) Keep each instruction as short as possible. Instructions should be as short as while 

conveying the essential message. Leave out unnecessary words. Try to keep sentences 

to 20 words or less. Providers are more likely to read short sentences. Short sentences 

are also easier to remember (10).

10) Watch the tone. Help clinicians, don’t threaten them. Often instructions tell providers, 

clinical staff or patients what to do if they somehow make an error and need to start 

again. The message about this must not blame the user. It must be in words that are 

clear to clinicians. It must have a friendly tone. individuals who feel blamed or shamed 

are less likely to make the necessary corrections (10).

11) Write in the positive. EHR instructions must be in the positive whenever possible. 

Rewrite double negatives as positive sentences because positive sentences are easier 

to understand. In English, two negatives make a positive. You can rewrite an English 

sentence that has two negatives into a simpler positive sentence (10).

12) Put the context before the action. Many instructions are sentences with two parts: a) 

what the user wants to do (the context, "to do...") and b) what the EHR user must do to 

accomplish that (the action, "do..."). EHR instructions must put the context before the 

action because research shows that if you give people the action before the context, 
40

many will begin to act before reading the end of the sentence. Errors will be made 

because they did not read all of the instruction (10).

13) Be consistent in the language of the instructions. EHR instructions must keep the 

same pattern for similar instructions because providers are very pattern-oriented. 

Patterns help people grasp information quickly and accurately (10).

14) Do not use gender-based pronouns. Instructions and statements that are addressed 

to both men and women must not use references to only one or the other gender. If the 

statement refers to a particular person, it is correct to use the appropriate gender 

pronoun for that person. Gender-based pronouns and words exclude the other gender 

from consideration in the mind of the EHR user (10).

15) Use simple English words. The words used in EHR systems must be the ones that 

clinicians understand. While all clinicians have achieved a certain level of training and 

mastery of the English language, they also come from many ethnic and cultural 

backgrounds which can impact understanding or translation of difficult, compound, 

complex or obscure words or words without direct translations in the providers native 

language (10).

16) Be consistent in the language that is used. Instructions and messages must use 

words consistently. Once you name something, use that name throughout the EHR 

system. Providers may be confused if the same object has different names and they 

may think that the instructions and messages are talking about different objects (10).

17) Do not use technical, computer jargon. This is a special case of the guideline to use 

words clinicians know. Instructions and all other material must talk to clinicians in their 

language and not use technical, computer words that they are likely not to know. Many 

clinicians are not familiar with computer terminology. If they do not understand the 

instructions, they may act incorrectly, and require increased time to find out what to do 

which will decrease efficiency, productivity (10).

18) Be explicit in naming buttons. This is another special case of using appropriate words 

and using simple English. Buttons must be meaningful to providers. Touching or 

otherwise selecting buttons on EHRs are one way that providers take actions. They must 

understand what they are choosing with each button (10).

19) Cover all important situations. Although we do not want to overburden providers with 

instructions, they must have instructions for relevant situations. Where there are no 

instructions, there is an implicit assumption that clinicians will know what to do by 

themselves. If that assumption is wrong, some providers will be confused and errors 

may occur (10).

20) Consider clinicians likely mistakes. Instruction writers must think about the ways that 

busy clinicians might misinterpret the instructions. They must write instructions to avoid 

those misinterpretations. People always bring their earlier experiences to new situations. 

They have expectations from those earlier experiences that may make them interpret 

situations differently from the way that is intended (10).

Guidelines for designing clear EHR system messages 

1) Understand the audience for messages about problems. On EHR systems, in 

addition to instructions and messages that clinicians see in the normal course of using 

the system, messages must be available for times when something goes wrong. It is 

imperative to understand the audience for messages about problems. The concern is for 
41

any message that might be seen by a clinician. If the message could come up while a 

provider is using the EHR, the message must be clear to providers. If a message could 

come up while a clinical staff person, student or patient is using the system, the 

message must be clear to them. EHR users span a very wide range of literacy, of 

English language skills, and of experience with computers. Many users (providers or 

patients) are older people who did not grow up with computers or have never used 

computers. 

2) Understand the context for messages about problems. It is important to understand 

the context for messages about problems. Troubleshooting messages appear only when 

the problem occurs. If a message comes up while a provider is trying to use the EHR it 

will almost certainly come as a surprise. The provider may have never seen the 

message before. Just seeing the message will be a source of stress and anxiety. These 

are all reasons why messages must be extremely clear, instantly understandable, 

include information on what to do, and be calming rather than blaming. All of these 

points are equally true for other clinical staff members, patients and caregivers who may 

also use the EHR. System messages can be greatly improved by following the following 

seven guidelines. 1) Do not call system messages “error messages”. 2) Do not blame 

the user. 3) Explain the problem succinctly. 4) If it is useful, explain the cause of the 

system message. 5) Tell the user what to do. 6) Using simple, common words. 7) Use 

simple illustrations only when they will help (10).

3) Messages and instructional material be designed and tested for specific patient, 

caregiver and consumer use cases and contexts. It is imperative that messages and 

instructional material be designed and tested for specific patient, caregiver and 

consumer use cases and contexts in addition to provider use cases and user contexts. 

As has been discussed above, it is faulty to believe that providers will be using EHRs 

without using these systems to interact with patients in the context of a clinical encounter 

or in another way. It should be considered essential to design and test all instructional 

messages and materials with a reasonable set of representative users to ensure the 

widest possible safe, appropriate and effective use of EHRs.

4.2.4 Include User Requirements in Product Specifications as a Prerequisite for EHR 

Certification

To help ensure that the best match is achieved between EHR features and user needs, it is 

recommended that user requirements be included in all EHR product specifications. This will 

allow potential users to make informed choices regarding the applicability of a given EHR 

product for a given set of user needs.

4.3 EHR Evaluation and Monitoring Guidelines

4.3.1 Include Evaluation of EHR Impact on a Target Set of Healthcare Disparities 

Indicators as a Part of the EHR Effectiveness, Post Adoption and Health Impact 

Evaluation

All efforts to document the effectiveness of EHR systems should include specific investigation of 

the EHR impact on healthcare disparities. To facilitate such evaluations, NIST should work in 

collaboration with the Agency for Healthcare Research and Quality, which currently produces 

the annual National Healthcare Disparities Report, and other appropriate federal, academic and 

industry collaborators, to define an EHR healthcare disparities indicator set. Once defined, it 

should be used as the basis for conducting ongoing Healthcare Disparities Impact 

Assessments. This work should be supplemented by additional qualitative research among 
42

safety net providers and patients from disparity populations to provide additional information 

regarding the nature, character, quality, magnitude and emergence of new determinants or 

elimination of current determinants of healthcare disparities impacted by EHR adoption and use.

4.3.2 Implement a National EHR Product Registry

Given the number and diversity of EHR developers and vendors as well as the diverse and 

dynamic needs of potential EHR users, it is recommended that a National EHR Product Registry 

be developed for all certified EHR products and other products which in the future are integrated 

into or otherwise linked with an EHR system. This registry should have standardized reporting 

requirements as outlined below. This registry would provide significant scientific research, 

consumer research, product safety and patient educational benefit, for potential EHR 

customers, users and providers.

EHR Product Reporting Recommendations Targeting EHR Vendors

4.3.2.1 Standardized Technical Elements & Design Feature Reporting

Certified EHR vendors should be required to report a standard set of technical and design 

features. The reporting requirements should be developed through a consensus driven process 

of public and private partners including healthcare disparities, disabilities, and underserved 

population’s expertise. Reported data should be publicly available.

4.3.2.2 Product Safety Information Reporting Requirements 

Certified EHR vendors should be required to report a standard set of product safety information. 

Because legacy systems will inevitably be used, this information should remain publicly 

available even after a particular product is no longer available.

4.3.2.3 Product Evaluation Information Reporting Requirements

Certified EHR vendors should be required to report a standard set of EHR evaluation 

information. In the future this should include any target user oriented voluntary certifications 

received by the EHR product. Evaluation information should include information about user 

requirements and product specifications.

EHR Product Reporting Recommendations Targeting Providers and Healthcare Systems 

4.3.2.4 Adverse Event Reporting

The National EHR Registry should facilitate voluntary provider and healthcare system adverse 

event reporting.

4.3.2.5 Provider Feedback

The National EHR Registry should also facilitate provider feedback regarding the EHR

challenges problems, malfunctions, errors experienced while using the system.

EHR Product Reporting Recommendations Targeting Patients, Consumers and Caregiver 
43

4.3.2.6 Patient Education

The National EHR Registry should provide culturally and linguistically appropriate patient 

educational information regarding certified EHR and associated technology. The information 

should be supplied by the product vendors but should comply with recognized federal standards 

for providing Culturally Linguistically Appropriate Services (See Glossary) and communicating 

information to diverse populations (11).

4.3.2.7 Consumer Feedback

The National EHR Registry should facilitate patient and consumer feedback about EHR

systems.

4.4 EHR Research Guidelines

4.4.1 Support Human Factors Research Regarding the Potential Impact, Opportunities 

and Barriers for EHRs to Reduce Healthcare Disparities 

While a significant volume of research has been done regarding user needs and 

accommodations, particularly in the human factors, ergonomics and disability fields, little of this 

work has been done from the perspective of healthcare disparities and therefore essentially no 

human factors and EHR work is found in the healthcare disparities literature. As such, ONC 

should continue to support research regarding the potential impact, opportunities and barriers 

for EHRs to reduce Healthcare Disparities as outlined below. These suggestions should not be 

viewed as an exhaustive nor comprehensive list of research needed to completely understand 

the human factors impact on healthcare disparities. Rather they represent suggested starting 

points for future work along these lines.

4.4.2 Evaluate the Human Factors Implications of Integrating Patient-Oriented 

Functionality into EHRs

Although, as discussed above, several significant policy precedents and initiatives are leading 

toward the increased patient and consumer use of EHRs, no research has been done to 

understand the health, healthcare or healthcare disparities implications of enabling consumer 

engagement with EHRs. Similarly, little is known about the potential value, efficacy or 

effectiveness of integrating personal health records and other consumer health informatics tools 

into more traditional EHRs. The evidence base for or against moving in this direction needs to 

be supported and developed.

4.4.3 Support the Development of Evidence-Based Criteria for Voluntary PopulationOriented Product Certifications

In addition to the recommendations contained in this report and the current evaluation process, 

it may be valuable to develop and incorporate voluntary user population based EHR evaluation 

(visually impaired, safety net, etc.). However the evidence base for or against this as a potential 

mechanism to help address healthcare disparities is currently not available and should be 

supported.

4.4.4 Evaluate Potential Differences in Information Design Needs, the Impact of These 

Differences and Opportunities for Accommodation across User Populations

It is not clear whether or not different populations of users (beyond providers and patients) have 

differing information design needs and whether or not such needs can impact healthcare 

disparities. Because information architecture is at the heart of any EHR usability, research in 

this area may have significant importance for addressing healthcare disparities via EHR

systems.
44

4.4.5 Evaluate the Human Factors Implications of Increased Stress (Workload Induced, 

User Environment Induced, Rural/Urban Residence etc) on EHR Accessibility, 

Usability, User Experience and Health Outcomes

To date, most of the research regarding stress and human-computer interaction has been done 

in the context of the work environment. However, as healthcare is increasingly being delivered 

in the home and community-based setting and as patients increasingly become engaged in their 

EHRs more research needs to be done to understand the potential impact of the home 

environment on EHR accessibility, usability, user experience and health outcomes.

4.4.6 Evaluate the Human Factors Implications of the Emerging EHR Health IT Workforce 

Working in Non Clinical Practice Settings (Home, Long Term Care Facility etc) on 

EHR Accessibility, Usability, User Experience and Health Outcomes.

A myriad of support personnel will inevitably be EHR system users. These include clinical 

office/practice managers, receptionist/schedulers and technical support personnel. Without 

these individuals involved, many providers would not be able to accomplish needed EHR data 

entry or report/summary requirements and needs. Also there is an emerging health workforce 

comprised of those individuals who provide or support care primarily in the home and 

community setting. It is likely that in order to maintain appropriate oversight and management as 

well as quality assurance and efficiency, these individuals will increasingly be using wireless 

handheld and tablet or laptop based mobile devices to input data into the HRH in real time, in 

the field, at the “point of care”. The implications of this emerging workforce on Health, 

healthcare outcomes and healthcare disparities needs to be evaluated.

5 Conclusions

In conclusion, significant scientific evidence attests to the fact that healthcare disparities exist, 

they are intractable and associated with increased healthcare costs, premature morbidity and 

excess mortality. Wide adoption and meaningful use of EHRs by providers and patients may 

impact healthcare disparities. The impact of EHRs on healthcare disparities are almost certainly 

going to be multifaceted, nuanced, in some cases indirect yet cumulatively significant. These 

disparities could improve, if EHR use and benefits, are equitably distributed across user 

populations. On the other hand, disparities could worsen, if some providers are not able to use 

EHRs or some patients not able to benefit from them. 

The fields of human factors engineering and ergonomics have made considerable contributions 

to our understanding of the possible barriers and potential solutions needed to ensure broad 

accessibility and usability of emerging EHR systems. Unfortunately, most of this knowledge and 

expertise, does not appear to be routinely considered during the EHR design and development 

process (7). In addition, little research along these lines, can be found, in the disparities 

literature. Few studies of EHR usability or health impact have been done from a healthcare 

disparities perspective. As such, much more research is warranted. There is also considerable 

need for federal policy leadership in this area. This leadership will help ensure that all providers 

are able to use EHRs and also help ensure that all patients are able to benefit from EHR use. 

Finally, given what is already known, much can be done now to reduce the risk of creating or 

exacerbating healthcare disparities. Product enhancements can be made by addressing key 

disparities-related design issues and by incorporating human factors engineering principles into 

the EHR design and development process. Significant progress along these lines will inevitably 

improve provider EHR adoption, help lead to reductions in healthcare disparities among affected 

populations and catalyze improvements in healthcare quality for all.
45

Glossary

Healthcare Consumers

For the purposes of this report healthcare consumers are defined as individuals do not have a 

clinical diagnosis provided by a licensed medical professional but who are seeking health 

information or health related services for the purpose of health maintenance, prevention or 

wellness

Patients

For the purposes of this report patients are defined as individuals who have an existing clinical 

diagnosis

Providers

For the purposes of this report providers are defined as any healthcare professional involved in 

the provision of medical services

Culture

Culture has been variably defined but in terms of the federal CLAS standards it is defined as the 

thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, 

religious, or social groups. Culture defines how health care information is received, how rights 

and protections are exercised, what is considered to be a health problem, how symptoms and 

concerns about the problem are expressed, who should provide treatment for the problem, and 

what type of treatment should be given. (11). 

Culturally and Linguistically Appropriate Services (CLAS)

The collective set of CLAS mandates, guidelines, and recommendations issued by the HHS 

Office of Minority Health intended to inform, guide, and facilitate required and recommended 

practices related to culturally and linguistically appropriate health services (11). 

Culturally and Linguistically Appropriate Services in Health Care

The CLAS standards are proposed as one means to correct inequities that currently exist in the 

provision of health services and to make these services more responsive to the individual needs 

of all patients/consumers. The standards are intended to be inclusive of all cultures and not 

limited to any particular population group or sets of groups. However, they are especially 

designed to address the needs of racial, ethnic, and linguistic population groups that are 

medically underserved. Ultimately, the aim of the standards is to contribute to the elimination of 

racial and ethnic health disparities and to improve the health of all Americans (11). 

The CLAS standards serve several purposes. They provide a common understanding and

consistent definitions of culturally and linguistically appropriate services in health care. They 

offer a practical framework for the implementation of services and organizational structures that 

can help health care organizations and providers be responsive to the cultural and linguistic 

issues presented by diverse populations (11).

Cultural and linguistic competence is defined as a set of congruent behaviors, attitudes, and 

policies that come together in a system, agency, or among professionals that enables effective 

work in cross-cultural situations. ‘Competence’ implies having the capacity to function effectively 
46

as an individual and an organization within the context of the cultural beliefs, behaviors, and 

needs presented by patients and consumers that are dissimilar to those of one’s self.” (11)

The CLAS standards are primarily directed at health care organizations; however, individual 

providers are also encouraged to use the standards to make their practices more culturally and 

linguistically accessible.

Standard 1. Health care organizations should ensure that patients/consumers

receive from all staff members effective, understandable, and respectful care that

is provided in a manner compatible with their cultural health beliefs and

practices and preferred language.

Standard 2. Health care organizations should implement strategies to recruit,

retain, and promote at all levels of the organization a diverse staff and leadership

that are representative of the demographic characteristics of the service area.

Standard 3. Health care organizations should ensure that staff at all levels and

across all disciplines receive ongoing education and training in culturally and

linguistically appropriate service delivery.

Standard 4. Health care organizations must offer and provide language

assistance services, including bilingual staff and interpreter services, at no cost to

each patient/consumer with limited English proficiency at all points of contact, in

a timely manner during all hours of operation.

Standard 5. Health care organizations must provide to patients/consumers in

their preferred language both verbal offers and written notices informing them of

their right to receive language assistance services.

Standard 6. Health care organizations must assure the competence of language

assistance provided to limited English proficient patients/consumers by

interpreters and bilingual staff. Family and friends should not be used to provide

interpretation services (except on request by the patient/consumer).

Standard 7. Health care organizations must make available easily understood

patient-related materials and post signage in the languages of the commonly

encountered groups and/or groups represented in the service area.

Standard 8. Health care organizations should develop, implement, and promote a

written strategic plan that outlines clear goals, policies, operational plans, and

management accountability/oversight mechanisms to provide culturally and

linguistically appropriate services.

Standard 9. Health care organizations should conduct initial and ongoing

organizational self-assessments of CLAS-related activities and are encouraged to

integrate cultural and linguistic competence-related measures into their internal

audits, performance improvement programs, patient satisfaction assessments, and

outcomes-based evaluations.

Standard 10. Health care organizations should ensure that data on the individual

patients/consumer’s race, ethnicity, and spoken and written language are collected
47

in health records, integrated into the organization’s management information

systems, and periodically updated.

Standard 11. Health care organizations should maintain a current demographic,

cultural, and epidemiological profile of the community as well as a needs

assessment to accurately plan for and implement services that respond to the

cultural and linguistic characteristics of the service area.

Standard 12. Health care organizations should develop participatory,

collaborative partnerships with communities and utilize a variety of formal and

informal mechanisms to facilitate community and patient/consumer involvement

in designing and implementing CLAS-related activities.

Standard 13. Health care organizations should ensure that conflict and grievance

resolution processes are culturally and linguistically sensitive and capable of

identifying, preventing, and resolving cross-cultural conflicts or complaints by

patients/consumers.

Standard 14. Health care organizations are encouraged to regularly make

available to the public information about their progress and successful

innovations in implementing the CLAS standards and to provide public notice in

their communities about the availability of this information.

Healthcare Disparities 

The Institute of Medicine defines healthcare disparities as differences in the quality of 

healthcare received by patients that is not due to access-related factors, clinical need, 

preferences or appropriateness of the health intervention (14). The causes of these disparities 

have not been definitively characterized. General consensus holds them to be related to 

population differences in 1) environmental exposures, 2) healthcare access, utilization and/or 

quality of care, (3). Within the U.S. healthcare system, these differences have most convincingly 

been demonstrated across racial and ethnic lines (Whites vs. minorities) (14). However other 

categorizations including geographic (urban vs. rural) (106), gender (male vs. female) 

(107;108), disability (disabled vs. non-disabled) (109-111), socioeconomic status (poor vs. nonpoor) (55;112), and age (non-elderly vs. elderly) (113;114) have also been described (3). Some 

authorities have sought to cast a distinction between healthcare disparities defined above and 

health disparities which have been defined population differences in health status that are 

thought to be related to broader societal factors (education, poverty, employment, stress etc) 

(115;116). The Institute of Medicine definition will be used for the purposes of this report (14).

Safety Net Providers

Safety net providers have been defined as those who deliver a significant level of health care to 

uninsured, Medicaid, and other vulnerable patients (6). In addition, core safety net providers

have two distinguishing characteristics. They (1) by legal mandate or explicitly adopted mission 

they maintain an “open door,” offering access to services to patients regardless of their ability to 

pay; and (2) a substantial share of their patient mix is uninsured, Medicaid, and other vulnerable 

patients. Core providers include a variety of health centers (e.g., community health centers, 

migrant health centers, the Health Care for the Homeless Program, school-based health 

centers, community-based clinics, public hospitals, and many teaching hospitals) (6). A 

substantial amount of safety net care is provided in hospital emergency departments, which, as 

a condition of participation in the federal Medicare program, are required to provide medical 
48

screening exams and stabilizing treatment to all patients, regardless of their ability to pay. In

addition, a considerable, but largely unquantified, amount of health care for safety net 

populations is provided in private physicians’ offices.

Usability

Usability is the effectiveness, efficiency, and satisfaction with which specific patients and 

providers can achieve a specific set of tasks in a particular environment. Ease of learning is also 

a component of usability. Efficiency is generally the speed with which patients and providers can 

complete their tasks. Effectiveness is the accuracy and completeness with which patients and 

providers can complete tasks. This includes how easy it is for patients and providers to make 

errors. User errors can lead to inaccurate or incomplete patient records, can alter provider 

clinical decision-making, patient self management decision-making and can compromise patient 

safety. User satisfaction is usually the first concept people think of in relation to “usability.” 

Satisfaction in the context of usability refers to the subjective satisfaction a user may have with 

a process or outcome. Efficiency, effectiveness, and satisfaction cannot be taken in isolation—

all three components must be evaluated and balanced based on your practice's goals and 

priorities (117).

Usability in the context of this report has little to do with the visual appeal of the user EHR 

system interface. Applications that use lots of colors or visual elements probably would have a 

lower usability “score” than well thought out designs that are simpler in appearance. Thoughtful 

use of visual elements can be a supporting factor that helps enhance product usability. 

Additional usability factors that must be considered in the design and development of EHRs, to 

prevent disparities among diverse patients and providers includes "ease of use" and "user 

experience." EHR systems are complex systems dealing with sensitive and sometimes 

confusing information. In terms of ensuring usability of these systems there is great need to 

analyze, test and address difficult aspects of EHR use such as counter intuitive interactions, 

confusing, misleading, or overly complex EHR system interface characteristics, logic of 

operation, differences from user expectations, - any of which could possibly lead to harm to 

patients or impact patient outcomes (118).

The term “accessibility” refers to design criteria, which remove barriers that make it difficult or 

impossible for some people with disabilities to use HIT. The intent behind accessibility is to 

implement the principle of non-discrimination. It is a way of demonstrating that healthcare 

entities (such as organizations, providers, academic institutions and companies) wish to be 

welcoming to all people, including people with disabilities (118).

User-Centered Design

User-centered design (UCD) is an approach to interactive system development that focuses 

specifically on making systems usable. It is a multi-disciplinary activity which incorporates 

human factors and ergonomics knowledge and techniques. The application of human factors 

and ergonomics to interactive systems design, enhances effectiveness and efficiency, improves 

human working conditions, and counteracts possible adverse effects of use on human health, 

safety and performance. Applying ergonomics to the design of systems involves taking account 

of human capabilities, skills, limitations and needs (117).

A plan should be developed to specify how the human-centered activities fit into the overall 

system development process. The plan should identify: a) the context of EHR use, specifying 

user and organizational requirements, producing prototypes and evaluating designs according 

to user criteria; b) procedures for integrating these activities with other system development 

activities, e.g. analysis, design, testing; c) the individuals and the organization(s) responsible for 

the human-centered design activities and the range of skills and viewpoints they provide; d) 
49

effective procedures for establishing feedback and communication on human-centered design 

activities as they affect other design activities, and methods for documenting these activities; e) 

appropriate milestones for human-centered activities integrated into the overall design and 

development process; f) suitable timescales to allow feedback, and possible design changes, to 

be incorporated into the project schedule (117).

Making systems more usable means systems can contribute to organizational aims and meet 

user and organizational needs better. Using a UCD approach can result in EHR systems that 

are easier to understand and use, thus reducing training and support costs. It can also improve 

user satisfaction and reduce discomfort and stress as well as improve the productivity and 

operational efficiency of organizations. Finally, it can also improve product quality, appeal to the 

patients and providers and can provide a competitive advantage. The complete benefits of 

human-centered design can be determined by taking into account the total life-cycle costs of the 

system including conception, design, implementation, support, use and maintenance (117).

Feedback from patients and providers is a critical source of information in user-centered design. 

Evaluating designs with patients and providers and improving them based on their feedback 

provides an effective means of minimizing the risk of a system not meeting user or 

organizational needs (including those requirements that are hidden or difficult to specify 

explicitly). Such evaluation allows preliminary design solutions to be tested against “real world” 

scenarios, with the results being fed back into progressively refined solutions. It is important to 

keep in mind that these evaluations need to be performed from the provider and patients 

perspectives. 

The most appropriate design cannot typically be achieved without iteration or without repeating 

a sequence of steps, until a desired outcome is achieved. This may be done at multiple points in 

the developmental cycle. User-centered activities can be iterated for individual parts of the EHR 

development process and again at a completed whole system level. Iteration should be used to 

progressively eliminate uncertainty during the development of interactive systems. Iteration 

implies that descriptions, specifications and prototypes are revised and refined when new 

information is obtained in order to minimize the risk of the system under development failing to 

meet user requirements (17).

The complexity of provider-EHR-patient interactions means that it is impossible to specify 

completely and accurately every detail, of every aspect, of the interaction, at the beginning of 

development. Many of the needs and expectations of provider, patients and caregivers that will 

impact on the design of the interaction, only emerge in the course of development, as the 

designers refine their understanding of the patients and providers and their tasks, or as patients 

and providers are better able to express their needs in response to potential solutions. Iteration 

of proposed solutions incorporating feedback from a user perspective provides a means of 

mitigating risk (17).

Using a user-centered approach to EHR design and development has substantial economic and 

social benefits for patients and providers, employers and suppliers. Highly usable systems and 

products tend to be more successful both technically and commercially (17). Support and helpdesk costs are reduced when patients and providers can understand and use products without 

additional assistance. In most countries, employers and suppliers have legal obligations to 

protect patients and providers from risks to their health, and safety and user-centered methods 

can reduce these risks. 

Universal Accessibility

The term “accessibility” in the context of this report refers to design criteria, which remove 

barriers that make it difficult or impossible for some people with disabilities to use HIT. Universal 
50

Accessibility focuses on removing barriers to utilization such that anyone can have the ability to 

use health IT. From this perspective, accessibility can be viewed as a means toward reducing 

healthcare disparities or achieving health equity in health IT or EHR access. Accessible HIT 

supports the needs of people with a variety of needs (118).

Universal Usability

Universal Usability is a design philosophy that attempts to make technology usable by all by 

focusing on a) user diversity, b) technology diversity c) bridging the gap between what users 

know and what they need to know (119). User diversity focuses on the variety of potential users, 

including those with different skills, knowledge, age, gender, disabilities, disabling conditions 

(mobility, sunlight, noise), literacy, culture, income, and so forth (9). Technology diversity 

focuses on using the most appropriate technologies (i.e. desktop computers, laptop computers, 

kiosks, tablets, mobile devices using various screen sizes and internet connection speeds) 

Conceptually, Universal Usability means designing for the purpose of enabling every user to

successfully use a given technology. Universal usability is often confused with universal access, 

which merely means having the equipment/technology and opportunity to use (119). There are 

many ways to fill the gap between what patients know and what they need to know about using 

health IT. Technology examples would include help menus or frequently asked questions. 

Accommodating a broader spectrum of usage situations require designers to consider a wider 

range of designs, but it also often leads to innovations that benefit all users (9).

While critics of Universal Usability exist, a recent Rand Corporation report on universal access 

made it clear that “better understanding of the capabilities and limitations of current usercomputer interfaces is needed.” In addition a National Academy of Science/National Research 

Council panel on every-citizen interfaces has recommended that “an aggressive universal 

usability research program, funded by government and private sources, that examines both the 

human performance side of interfaces and the interface technologies, current and future 

potential” be established (9). This report and subsequent federal efforts to research, evaluate 

and ensure Universal access and usability in the area of EHR systems represents a critical 

component of the Federal Governments’ leadership along these lines.

Disclaimer

Any mention of commercial products or reference to commercial organizations is for information 

only; it does not imply recommendation or endorsement by NIST nor does it imply that the 

products mentioned are necessarily the best available for the purpose.
51

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