MedStar Human Factors Center Launches and Encourages Action

On Feb. 4, 2019, the MedStar Health National Center for Human Factors in Healthcare launched and a related campaign, presenting compelling evidence for the need to address the known risks to patient safety and clinician burnout that stem from poor electronic health record (EHR) usability—and calling for action.

The website, which was launched in collaboration with the American Medical Association, makes videos from the clinician’s point of view available for the first time to demonstrate the risks and challenges caused by poor EHR usability, which is the extent to which the technology can be used efficiently, effectively, and satisfactorily. The site also specifically calls out what multiple stakeholders—policymakers, healthcare providers, EHR vendors, and patients—can do.

The theme of the website and campaign is ‘Everybody Has Responsibilities’ to stress the need for increased collaboration. As a shared opportunity for action, stakeholders can sign the MedStar Human Factors Center’s letter to elected leaders of the United States Senate and House committees that can prioritize EHR usability and safety in their oversight of new policies being put in place by the Department of Health and Human Services. Click here to sign the letter to Congress by Feb. 28, 2019, the month that marks the 10-year anniversary of the federal act that successfully promoted the widespread adoption of EHRs.

For a deep dive into the research and thought leadership informing that letter, read the Journal of the American Medical Association Viewpoint, “A Decade of Health Information Technology Usability Challenges and the Path Forward,” which was written by Raj Ratwani, PhD, who leads MedStar’s Human Factors Center, and two co-authors, all of whom serve as top EHR usability and safety experts.

Learn more about the videos and campaign in MedStar’s press release: “Experts Call for Safety Improvements as Widespread EHR Adoption Reaches 10 Year Milestone.”

Media Contact

Marianne Worley
[email protected]

Journal of the American Medical Association: Improving Electronic Health Record Usability and Safety Requires Transparency


On Nov. 29, 2018, the Journal of the American Medical Association published a viewpoint article titled, “Improving Electronic Health Record Usability and Safety Requires Transparency,” by authors from MedStar Health’s National Center for Human Factors in Healthcare, American Medical Association, and Brigham and Women’s Hospital.

The opinion piece examines how gag clauses in EHR vendor and healthcare provider contracts block providers from openly addressing EHR usability and safety issues, representing “a market failure.” Despite the 21st Century Cures Act inviting action to help prevent this in 2016, the Office of the National Coordinator (ONC) of Health Information Technology has yet to define what constitutes blocking EHR usability and safety information. The article discusses three main criteria the ONC should consider in doing so and why it’s critical to act on this now.

Learn more about the background and policy recommendations tied to this issue in MedStar’s related press release: “3 Policy Changes That Could Make Electronic Health Record Systems Safer and Easier to Use.”

Photo Credit: Health Affairs.

Media Contact

Marianne Worley 
[email protected]

Health Affairs: Identifying Electronic Health Record Usability And Safety Challenges In Pediatric Settings


On Nov. 5, 2018, the health policy journal Health Affairs published an article by MedStar Health’s National Center for Human Factors in Healthcare and its collaborators titled, “Identifying Electronic Health Record Usability and Safety Challenges in Pediatric Settings.”

It reported that electronic health records (EHRs) may present a significant risk to the health and safety of children. Of 9,000 analyzed pediatric reports more than one third described a medication error that was related to EHR usability. The findings emerged from the analysis of pediatric patient safety event reports that were likely to be related to EHRs and medication, gathered from three healthcare systems.

Learn more about the findings, related stakeholders, and calls to action in MedStar’s press release: “Additional Safety Measures Recommended After Study Finds EHR Usability Issues Pose Risk to Children.”

Raj Ratwani, PhD, director of MedStar’s Human Factors Center and a lead researcher and author, also discussed the study further on Nov. 6 as part of a Health Affairs briefing on its full “Patient Safety” issue, where numerous article authors commented on the best and latest research on this topic. Click here to read more and watch the recorded webcast.

Photo credit: Health Affairs.

Media Contact

Marianne Worley
[email protected]

5 Recommendations to Make EHRs Safer for Pediatric Patients

MedStar Health and Pew Charitable Trusts Respond to Congressional Act

September 10, 2018

Washington, D.C. (September 10, 2018)—Experts with MedStar Health’s National Center for Human Factors in Healthcare have leveraged their past research into the safety and usability of electronic health records (EHRs) to join with The Pew Charitable Trusts in offering recommendations to the federal government for making the health IT systems safer for children, whose unique needs make them particularly vulnerable to documented EHR usability and patient safety issues. The recommendations were published today by the American Medical Association in its journal JAMA Pediatrics, in a Viewpoint article entitled “Improving Pediatric Electronic Health Record Usability and Safety through Certification.”

The authors are Raj M. Ratwani, PhD, with National Center for Human Factors in Healthcare, and Ben Moscovitch, MA, and Josh P. Rising, MD, with The Pew Charitable Trusts.

Their recommendations are in response to a provision in the 21st Century Cures Act, passed by Congress in 2016, for the Office of the National Coordinator to develop a voluntary program that would certify EHRs in a way that accounts for unique issues in pediatric care.

“Children have unique healthcare needs, and oftentimes care processes that may work well for adults do not work for children,” says Dr. Ratwani. “While we have recognized the unique needs of children when it comes to things like medications, we have not recognized this need when it comes to technology like the electronic health record.” EHRs, which are almost universally used across the United States to manage patient care, are not tailored to the unique needs of children or clinicians who treat them, and this can put pediatric patients at risk.

The authors cite a couple of instances where the poor usability of EHRs has contributed to potential harm:

  • Medication dosages for children are based on weight, and poor EHR usability has contributed to overdoses being given when a confusing EHR display makes it difficult to enter a child’s correct weight.
  • Age-appropriate vaccinations may be overlooked due to the EHR’s failure to notify the clinician of a needed vaccine or the wrong vaccination may be given when the EHR recommends a vaccine that is inappropriate given the child’s age.

The authors provide these five recommendations for a certification program:

  • Require EHR vendors to provide evidence that they are employing a user-centered design process.
  • Require that usability test participants represent the clinical end users.
  • Define and require the use of rigorous test cases to assess usability and safety.
  • Recognize that EHR implementation is crucial to safety, and consider the entire EHR life-cycle—not just the development phase—when granting certification.
  • Encourage transparency in sharing usability and safety challenges to improve safety and EHR product.


About the National Center for Human Factors in Healthcare

The National Center for Human Factors in Healthcare occupies a unique position in the United States as the largest human factors program embedded within a healthcare system. It brings together human factors scientists, systems safety engineers, health services researchers, and clinicians to conduct safety science and applied research in medicine to improve safety, quality, efficiency, and reliability. The center is part of the MedStar Institute for Innovation and is affiliated also with the MedStar Health Research Institute. MedStar Health, the parent organization, is the largest not-for-profit healthcare provider in the Maryland and Washington, D.C., region, with 10 hospitals and an extensive ambulatory services network, and is the medical education and clinical partner of Georgetown University.

Media Contact

Marianne Worley
[email protected]

The Pew Charitable Trusts: Ways to Improve Electronic Health Record Safety

On August 28, 2018, The Pew Charitable Trusts released a landmark report providing important criteria to support usability and safety throughout the EHR life cycle.

The report—published in partnership with the MedStar Health National Center for Human Factors in Healthcare and the American Medical Association—provides guidance in two key areas:

  • Recommendations on how to advance usability and safety throughout the EHR software life cycle, which can be used as the foundation for a voluntary certification process for developers and EHR implementers.
  • Criteria detailing what constitutes a rigorous safety test case and the creation of sample test case scenarios based on reported EHR safety challenges.

Read the report titled “Ways to Improve Electronic Health Record Safety” for more on our voluntary certification process recommendations, rigorous test case criteria and example scenarios.

You can also view related coverage from Bloomberg, EHR Intelligence, Health Leaders Media, Becker’s Health IT, Digital Commerce 360, Healthcare Dive and Health IT Analytics, as well as on the “Notes from Neil” blog.

CBS Baltimore: MedStar Aiming to Improve Safety with New Training Center in Baltimore

MedStar Simulation Training & Education Lab’s (SiTEL) expanded Baltimore simulation center is bigger and more realistic than ever, giving clinical and non-clinical associates hands-on training without risking patient safety.

 “What we’re attempting to do is make a safer medical environment,” said John Yosaitis, MD, medical director at MedStar SiTEL.

The lab isn’t just for doctors and nurses. Everyone who has a role in caring for a patient, even those who clean the rooms, will have a chance to train throughout their careers. Training areas are built to mimic areas of the hospital and can be equipped to support future training modalities such as virtual reality.

Watch the full story from CBS Baltimore.

MedStar Health Expands Use of Simulation Training to Teach Patient Care

Celebrates Launch of its Largest Innovative Sim Center Near MedStar Harbor Hospital


BALTIMORE—(May 21, 2018)—MedStar Health will celebrate the expansion and renovation of the Baltimore Clinical Simulation Center, part of the MedStar Simulation Training & Education Lab (SiTEL), where MedStar associates receive critical hands-on training in caring for patients. Members of the media are invited to get a sneak peek of state-of-the-art technologies, and test their medical emergency response skills using virtual reality, with a media-only tour of the facility, May 24th at noon.

WHAT: Exclusive Media Tour and Virtual Reality Demo
WHEN: Thursday, May 24th at 12:00 noon          
WHERE: Baltimore Clinical Simulation Center: 2990 S. Hanover Street, Baltimore 21225 (across from MedStar Harbor Hospital)

The Baltimore Clinical Simulation Center is the largest of MedStar Health’s four training centers, all designed to enhance patient safety through the continuous development of our associates’ skills. To engage residents, nurses and other associates, MedStar SiTEL uses interactive online and face-to-face training, including 3-D virtual reality and hands-on, high-fidelity simulation.

MedStar’s expanded Baltimore Clinical Simulation Center is also equipped for training non-clinical associates who play a key role in patient care. A new program, developed with Crothall Healthcare, teaches Environmental Services associates to identify and resolve common hazards in the healthcare environment. Participating associates also learn how to use the Surfacide Helios disinfectant system. 

“MedStar Health strives to provide a highly realistic environment through our clinical simulation centers where associates can learn and safely practice critical skills and gain experience before they lay a hand on a patient,” said Bill Sheahan, vice president of SiTEL. “The expansion and renovation of our Baltimore simulation lab enables us to provide more innovative programs designed to enhance the safety, quality of care, and overall experience for our patients.”

The simulation lab encompasses nearly 12,000 square feet of flexible training space. New learning environments mirror high-profile areas of hospitals, including simulated operating rooms and patient rooms for emergency, labor and delivery, and medical-surgical treatment. It has four large simulation bays, each equipped with technology to allow for monitoring performance and communication between learners and instructors. Spaces can be equipped with a variety of high-fidelity mannequins and task-based training equipment, where learners develop new skills or reinforcing existing skills such as CPR or central venous access.   

About MedStar Health
MedStar Health is a not-for-profit health system dedicated to caring for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation and research. MedStar’s 30,000 associates, 6,000 affiliated physicians, 10 hospitals, ambulatory care and urgent care centers, and the MedStar Health Research Institute are recognized regionally and nationally for excellence in medical care. As the medical education and clinical partner of Georgetown University, MedStar trains more than 1,100 medical residents annually. MedStar Health’s patient-first philosophy combines care, compassion and clinical excellence with an emphasis on customer service. For more information, visit

Media Contact: Debra Schindler
Phone: 410-274-1260
Email: [email protected]

HealthTech Magazine: Healthcare Treatment, Training Reaches New Heights with VR

Photo Credit: Gary Landsman

Decisions that emergency staff at a hospital make in the first 20 minutes of a patient’s arrival can mean the difference between life and death; therefore, sharpening the emergency skills of doctors and nurses is crucial. HealthTech Magazine highlights an ambitious project at MedStar SiTEL, which uses virtual reality headsets to bring clinicians together in lifelike, 3D simulations of a modern emergency room, where they can prepare for such scenarios.

“Training improves safety, reduces risk and contributes to better outcomes,” says Bill Sheahan, director of MedStar SiTEL. “Ideally, we’d like to see our people practice all the necessary skills, as often as possible.” 

The New York Times: The Hospital Gown Gets a Modest Makeover

hospital gown
















MedStar Montgomery Medical Center will soon start piloting a “reimagined” hospital gown—The Patient Gown by Care+Wear x Parsons—while possibilities for its broader use are evaluated by the MedStar system. The new gown design is intended to better support patient privacy and comfort while ensuring clinicians have necessary access to the body to provide care.

As MedStar Institute for Innovation (MI2) Director Dr. Mark Smith explains from the clinician perspective: “It gives you terrific access, and the patient feels safe and protected and comfortable.”

MedStar began working with Care+Wear through the #Patient2Consumer startup challenge it co-hosted with 1776 in July 2017, which attracted businesses advancing consumer-friendly healthcare innovations. Care+Wear is one of four winners participating in the MedStar Innovation Lab cohort, running from October 2017 through January 2018, which offers startup leaders regular access to MedStar and 1776 mentors among other resources and opportunities.

Click here to read the article by The New York Times.

Related stories have also been shared regionally by Washington Business Journal and Baltimore Business JournalWTOPUVA TodayThe Baltimore Sun, and CBS Baltimore among others. 

The Pew Charitable Trusts: Improving Patient Care Through Safe Health IT

terry fairbanks md at xray screen

On Dec. 19, 2017, The Pew Charitable Trusts released a new report and video on its collaborative electronic health record usability and safety efforts with MedStar Health and its National Center for Human Factors in Healthcare

Read the report titled "Improving Patient Care Through Safe Health IT" spotlighting how collaboration can improve the safety of patient health records. 

View the related video featuring MedStar Health National Center for Human Factors in Healthcare leaders Rollin “Terry” Fairbanks and Raj Ratwani.