Usability and the Future of the EHR

Many articles have been written correlating the weakness of  EHR usability and patient safety.  As a physician and EHR user, here are some key points that an EHR of the future, and the healthcare IT environment in which it lives, should address and push for.

1. A NATIONAL DATABASE: Creation of a national healthcare database with the intent of including every individual, with records presented via a standardized format.

a.Yes, this is a bit far off, and there are obstacles. However, we feel this goal is so key that planning and development now should take into account the needed sub-steps along the way, for its achievement. Otherwise, we will continue to be untangling spaghetti for eons.

b. Such a central database would streamline access to health information for every patient interacting with any Electronic Health Record in the country.  While the term "interoperability" is frequently tossed around, the fundamental point of interoperability is ability to easily share information. Central storage is not really necessary, but centralized access is.

b. Direct incentive-type funding.  Meaningful use was an understandable first effort. But putting huge incentives into time and work consuming data collection queries, has made providers suffer, with little benefit. When a national database is available, information can be more easily examined to determine how EHRs are being used in identifiably meaningful ways. 

c. Movement in this direction would be like putting the money in the bank.  As it became established, it would be a fundamental and available resource.

2. STANDARDIZATION OF CPOE: Creation of a standardized national Computerized Order Entry (CPOE) system with its user interface replicated at every care-site care would generate huge improvements in safety and efficiency. Modifiable order sets for key presentations could be built and maintained by specialty/sub- specialty authorities, and adjusted to meet local needs. 

a.  This would represent a significant advance, allowing providers of all stripes to interact with local systems when directing care, without endless learning curves.

b. Optimally, the entire staff should be able to use the system rather than the highest paid providers being the data input clerks. Various levels of authority would allow hierarchical verification and acknowledgement of orders, promote safety, discussion of clinical course, and appropriate supervision of ordering.

c. One would expect that developed orders would be care-setting specific (modular) and provide the most common orders in easy array of choices.

d. Order interaction with the pharmacy should also be care-setting specific i.e Emergency Department, operating room etc. Moreover, prescriptions/e-prescribing should be care-setting, care-track, and provider specific.

e. Simplification could be globally anticipated. For example calculators (such as pediatric dosing, and other weight/age based therapies) could be straight-forward and easy to use (see the local ATM)

3. INTELLIGENT CLINICAL DECISION SUPPORT: It is time for research to progress in the realm of clinical decision support. Artificial Intelligence is making its way into the world (think Siri), and medicine should not be behind in this exploration. 

a.  A real potential benefit of an EHR in clinical care is in the promise of AI. Right now, most of the research needed on any one case is still on our shoulders. Who of us does not do a google search or explore a reliable source (like "Up-to-Date") on a frequent basis to support of clinical decisions.  The butler (Siri's colleague) can help do that for us. 

b. A good system ought to be aware of your needs, even before you are conscious of them.  Should not a differential diagnosis be automatically generated from the information within your CC, HPI?  If the computer recognizes certain symptom complexes, the provider is supplied can be given easy access to information, treatment protocols, policy recommendations, and appropriate reminders to consider key diagnostic options.

c. Also included should be medication alerts that indicate potential severity of pharmaceutical choice and dose.

4.   SIMPLIFICATION: in the design, construction, and implementation of the actual EHR. For example:

a. Make nursing notes, provider notes, labs, x-ray reports, etc. accessible without having to go to multiple screens to find them.  This is technology available now.  Tabs, mouse-overs, and other tools should be fully implemented in the EHR space. (Google News is a good example of a summary presentation that includes all potentially important items)

b. Artificial intelligence/decision support suggestions should appear in a way that supports the provider’s ability to look over and collate all the data.

c. Another example exists in the sometimes disparate modules that comprise an enterprise EHR.  Direct interaction between the EHR and the tracking board is essential to assist providers and caregivers in controlling a flood of information and prioritizing decision making. Why put information in twice, three times, or more?

These are just a few suggestions. Please add your own below. Let's help make the record a real-time clinical assistant instead of just a medical-legal document and a billing tool for reimbursement.

10 Things Medical Records Won't Tell You!

The Wall Street Journal published an article last week on the 10 things medical records won't tell you.  I have condensed the list, so you get the idea...

1. COST: The price tag is HUGE!
2. SHARING IMPORTANT CLINICAL INFORMATION between providers is a myth.  Even high-price tag enterprise level systems do not do this well, or cannot, especially between different hospitals and doctors.
3. DOCTORS HATE IT in general and pretty consistently, especially if forced to use it by their hospital, the government, or partners.
4. DOCTORS HAVE LESS TIME to spend with patients...because they have to fiddle with machines.
5. PRIVACY physicians may employ strangers such as scribes to manage there cumbersome EHR into the previously sacred and secure doctor-patient relationship.
6. ERRORS MAGNIFIED mistakes are easier to make; just hit the wrong key, or have a voice recognition system hear "no chest pain" instead of "known chest pain".
7. INFORMATION OVERLOAD TMI- too much information...sometimes, in fact most of the time, we just don't need or want to read "War & Peace" on every patient, and only a section of the total is needed in any clinical situation.  But the EHR commonly gives it all. No one, especially not clinicians, have the time to read it.
8. IDENTITY THEFT EHR's contain much of your demographic information--social security, payment, address, phone, work schedule, etc.  They are therefore a fertile ground for the thieves that prey on such things.
9. YOU BECOME A MARKETING STATISTIC your information will be marketed and sold e.g. to pharmaceutical companies, insurance companies, etc.
10. BIG BROTHER IS WATCHING the government can and will track the events that occur in medical interactions through EHRs.  The requirements and criteria for this sort of tracking are already in place.

Choose an Electronic Health Record that has thoroughly considered these complaints and actively deals with them.  Complaint #10- government policies and incentives is the biggest driver in turning to EHR.

Could Your Electronic Health Record Function Without Workarounds?

The Electronic Health Record is a complex tool that hopefully improves communication, fix the legibility issue, and decrease medical errors.  However, the "Devil is always in the details".

Wikipedia states a workaround is a bypass of a recognized problem in a system.  A workaround is typically a temporary fix that implies a genuine solution to the problem is needed.  But workarounds are frequently as creative as true solutions, involving outside the box thinking in their creation.

Computer software that causes a computer to perform useful tasks beyond running the computer itself is called Application software, program, or app.

A GUI widget or control is an element of a Graphical user interface- GUI that displays information arrangement changeable by the user, such as a window or text box.  The defining characteristic of a widget is to provide a single interaction point for the direct manipulation of a given kind of data.

A true test of your EHR is:

1. How many workarounds, apps and widgets are necessary additions to make the program usable?
2. Are these add-ons value added or desperately needed to succeed?

These include some of the following resources: Scribes, Physician Assistants, Nurse Practitioners, Medical Assistants, Voice activated technology, Cut and paste, Macros, Typing courses, Artificial intelligence, Warnings, Error notifications, etc.

Some of these additions can add major value superimposed on an efficient, walk-up usable computer program.  The problem is they are necessary at great cost to survive the electronic world.

Factors that Affect Usability

One of the recurring themes of practitioners is that EHR programs lack of easy, intuitive usability that creates major work-flow issues.  These problems directly affect throughput, efficiency, and provider work satisfaction.  These factors ultimately lead to a 15-20% decrease in productivity, while forcing providers to add additional services like scribes and mid-level providers.  Bottom line:  costs are up, income is down, and generalized unhappiness is rampant.

 

The following tech blog analyzes the cost of poor usability on productivity.  Hope you find it informative.

 

http://blog.technologyevaluation.com/blog/2013/05/08/can-you-afford-not-to-invest-in-usability/