Darwinian health IT: Only well-designed EHRs will survive

Remember the Ford Pinto and the AMC Pacer, aka the Pregnant Pinto? Both serve as reminders of an in era in which the American auto industry lost its way and assumed drivers would buy whatever they put on the lot. Foreign competition, primarily from Japan, filled the void created by American apathy for quality and design, and the industry has never been the same.

Admittedly, the comparison of cars and EHRs is less than apt, but health IT also assumes healthcare will buy what we’re selling because the feds are paying them to. And, like the Pinto, what we’re selling inspires something less than awe. In short, we are failing our clinical users.

Why? Because we’re cramming for the exam, not trying to actually learn anything.

Myopic efforts to meet certification and compliance requirements have added functionality and effort tangential to the care of the patient. Clinicians feel like they are working for the system instead of it working for them. The best EHRs are focused on helping physicians take care of patients, with Meaningful Use and ICD-10 derivative of patient care and documentation.

I recently had dinner with a medical school colleague who gave me insight into what it’s like to practice in the new healthcare era. A urologist in a very busy Massachusetts private practice, he is privileged to use what most consider “the best EHR.”

Arriving from his office for a 7 PM dinner, he looked exhausted, explaining that he changed EHRs last year and it’s killing him. His day starts at 7 AM and he’s in surgery till noon. Often double or triple booked, he sees 24 patients in the afternoon, scribbling notes on paper throughout as he has no time for the EHR. After dinner he spends 1.5 to 2 hours going over patient charts, dictating and entering charges. What used to take 1 hour now requires much more with the need to enter Meaningful Use data and ICD coding into the EHR.  He says he is “on a treadmill,” that it should be called “Meaningless Use,” and he can’t imagine what it will be like “when ICD-10 hits.”

My friend’s experience is representative, not anecdotal. A recent survey by the American College of Physicians and American EHR Partners provides insight into perceptions of Meaningful Use among clinicians.  According to the survey, between 2010 and 2012, general user satisfaction fell 12 percent and very dissatisfied users increased by 10 percent.  Michael S. Barr, MD, MBA, FACP, who leads ACP’s Medical Practice, Professionalism & Quality division, drew this conclusion:

Dissatisfaction is increasing regardless of practice type or EHR system. These findings highlight the need for the Meaningful Use program and EHR manufacturers to focus on improving EHR features and usability to help reduce inefficient work flows, improve error rates and patient care, and for practices to recognize the importance of ongoing training at all stages of EHR adoption.

Additional survey results show dramatic and pervasive dissatisfaction:

  • Clinicians who would not recommend their EHR to a colleague increased from 24 percent in 2010 to 39 percent in 2012.
  • 34 percent of users were “very dissatisfied” with the ability of their EHR to decrease workload — an increase from 19 percent in 2010.
  • 32 percent of responders had not returned to normal productivity since EHR implementation compared with 20 percent in 2010.
  • Dissatisfaction with ease of use increased from 23 percent in 2010 to 37 percent in 2012.
  • Satisfaction with ease of use dropped from 61 to 48 percent.

Clearly, the usability of EHRs has gotten worse with the implementation of Meaningful Use. Many have been coded to certification requirements, not designed to make achieving Meaningful Use a byproduct of improved workflow automation. Where basic EHR usage is not already established, bolted on functionality forces clinicians to take additional steps that further disrupt workflow.

The tag line is that usability and good design matter. They always have. An elegant, flexible system can accommodate new requirements. Adding more stuff to an incoherent system just creates an unmanageable mess.

Consider clinician satisfaction with the usability of leading enterprise EHRs according to the ACP survey.  When asked which system were most usable, results show that clinicians ranked VistA best overall with a score of 4.06, ahead of Greenway (3.83), EpicCare (3.51), McKesson (3.10), Meditech (3.08), Allscripts (3.06) and Cerner (2.93). This is no accident. Built long before Meaningful Use, VistA was designed with physician and patient needs foremost. Indeed, VistA was one of the EHRs the Office of the National Coordinator evaluated to come up with Meaningful Use criteria.

Physicians need and desire systems that help them do their work, and only those systems that are designed with clinical efficiency—not mandated behavior—in mind will accomplish this task. Again, Meaningful Use measures and their health IT representation should be derivative, not additional, which requires iterative real-world design. The systems that score the highest have been pounded on by physicians for years. Their development teams obviously listened to end users.

According to Modern Healthcare, natural selection may already be taking place in the EHR environment as Meaningful Use 2014 and Stage 2 introduce more exacting requirements. The magazine’s review of federal records shows a massive drop in the number of health IT systems being tested for Stage 1 2014 and Stage 2 certification.  While around 1,000 EHR technologies were certified for 2011 Stage 1 requirements, as of last week only 79 systems were certified for 2014 standards. Almost all companies are scrambling. Some will get certified in time. Many more won’t.

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