Researchers and patient safety advocates have often warned about the association between EHR usability and patient harm, but hard numbers have been difficult to pin down.

However, new research shows just a small percentage of patient safety events can be traced back to specific aspects of EHR usability. The study, published this week in JAMA, reviewed 1.7 million events reported to the Pennsylvania Patient Safety Authority and from a large multihospital academic medical center between 2013 and 2016. The authors found just 0.11% of events explicitly mentioned an EHR vendor or product and just over 500 events (0.03%) includes language explicitly referencing EHR usability.

The most common categories were data entry and alerting, making up nearly half EHR-related events.

Despite the low percentages, lead author Raj Ratwani, Ph.D., argued the conservative parameters—including limiting the analysis to events that named one of the top five largest vendors within one state—indicated the events they identified were “just the tip of the iceberg in the grand scheme of things.”

Broadly, patient safety incidents are notoriously underreported, and the likelihood that a clinician would include the name of the EHR vendor tightens those parameters even farther.

“We really wanted to be deliberate and concrete in the way we looked at this data,” Ratwani, the scientific director of the MedStar Institute for Innovation’s National Center for Human factors told FierceHealthcare. “We didn’t want to put numbers out there that people might argue with.”

Those conservative estimates underscore the need for greater industry collaboration between vendors and providers and to optimize federal policy. Ratwani points specifically to two provisions of the 21st Century Cures Act that require transparent reporting around EHR usability and real-world testing for interoperability.

Although it isn’t included in Cures, Ratwani also supports a national health IT safety collaborative, something organizations like the ECRI Institute and Pew Charitable Trusts have recently called for.

He also pushed for federal agencies, like that Agency for Healthcare Research and Quality (AHRQ), which funded the JAMA study, to support further research into EHR safety events, regardless of how low those percentages may seem. And he worried the results might lead some to dismiss the potential for harm.

“Our level of acceptability here should be zero,” he said. “We should be striving for no harm events, particularly because there’s a deep science behind usability; we know how to make these systems well designed.”