Wanted: Simpler, easier to use EHRs

Providers who have them are only mildly satisfied; those who don't have them yet are wary.
By Mike Miliard
03:56 PM
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Adoption of electronic health records continues to make inroads, with six in 10 healthcare providers having at least part of an EHR system in place, according to the fourth annual "Healthcare IT Insights and Opportunities" survey from IT trade association CompTIA. Still, satisfaction with most systems is lacking.

CompTIA polled 375 doctors, dentists and other care providers, and found a satisfaction rate averaging in the low 60s – indicating "acceptable performance," but leaving much room for improvement, researchers say.

[See also: CompTIA introduces HIT technician certificate]

Among their complaints, providers say they want better ease of use, improved interoperability with other systems, faster speeds, more vendor training and improved remote access and mobility features.

The survey generally finds positive attitudes toward EHRs, especially compared with past polls.

"As users move along the learning curve they become more adept and efficient in leveraging the capabilities of EMR/EHR systems," researchers write.

Still, "relatively few adopters fully understand what an EMR/EHR implementation entails," according to CompTIA. "While many healthcare providers anticipated the disruption associated with a significant workplace transformation, 40 percent indicated their EMR/EHR implementation was actually worse than expected."

[See also: EHR adoption could exceed 80 percent by end of 2013, new study finds]

"Granted, 56 percent  also acknowledged being less than optimally prepared for the transition to EMR/EHR," the report notes. "Additionally, a sizable percentage of healthcare providers didn’t fully understand the impact to workflow, which inevitably may have contributed to frustration. The take-away: for the unprepared, an EMR/EHR implementation can be a challenging endeavor."

Vendors have their work cut out for them if they want to prosper into the future, according to CompTIA.

Providers want vendors to offer "quality from start to finish," the report shows. They want them to deploy EHR systems and ensure they work right; to train them and their staff; to provide and install updates to the system – preferably wirelessly; to offer remote monitoring around the clock, and proactively fix issues as soon as the problem occurs.

"IT solution providers must be extra diligent in communicating the steps of the implementation plan, especially in the pre-implementation stage," according to the report. "This can go a long way towards allaying concerns. For many healthcare providers a transition to EMR/EHR entails not only a physical change in workflow, but also a change in mindset."

With the next wave of EHR adoption to occur among small and mid-size practices, many are still wary of the technical, workflow and cost hurdles, the report shows. Healthcare IT News asked Tim Herbert, CompTIA's vice president research, to elaborate on the report's findings, and to offer some thoughts for providers who are skeptical of making the leap.

Q: Your report shows that 58 percent of providers would be more satisfied with EHRs if they were simpler to use. Why is user-centered design still such a problem with this technology? And what needs to happen to get developers to start paying more attention to it?

A: There are likely several factors at play. It’s not uncommon for an EHR system to have started out with a simple, functional design capable of performing a few tasks really well. Over time, in response to user demands, competitive pressures or compliance requirements, features are bolted on and the software gets more complex and unwieldy. Software developers constantly face the delicate balancing act of meeting user demands for features/capabilities (which typically adds complexity) and keeping the system easy to use. EHRs that fall into the trap of trying to be all things to all users (e.g. from large hospitals to small primary care practices to specialists), inevitably produce a product that is adequate for each, but great for none.

Another factor that may be affecting the responses in the research is changing user expectations. Over the past few years, products designed for the consumer market have been adopted by the business world (think Twitter, Skype, Facebook, DropBox, Google Docs and so on). These web-based systems, with a heavy focus on the user experience, makes many legacy systems originally designed to run locally on a firm’s server look especially dated. This phenomenon is affecting software perceptions across the entire range of applications used by business. The trend towards the cloud-based software-as-a-service model continues to gain momentum, and with it, probably increasing pressure to focus more on design and the user experience.

Lastly, and this gets to the question below, the research indicates a segment of healthcare providers expresses concern over selecting an EHR system from a firm that may not be around five years from now. Consequently, they may pass on an innovative start-up with strong user-centered design in favor of a well-established EHR vendor, even if it means adopting a more complex system. Some of the dissatisfaction voiced in the research may be self-inflicted, meaning the healthcare provider may have selected a less-than-optimal EHR system for their needs.

Q: With technology changing so fast – and federal regulations seeming to mount by the year – investing in health IT can seem daunting, especially for smaller providers. What should they be looking for in a potential vendor to make sure they're not doing the dreaded "rip and replace" in a few years time? Things will be very different in healthcare by then … how to best ensure they'll still have a good technology partner that is evolving along with them?

A: Unfortunately there are few absolute assurances over the long-term. Even large vendors merge or are acquired, which could affect the user. With that being said, there are a few elements of due diligence that can help minimize certain risks.

First, it’s important to have a formal evaluation plan. A structured approach forces the provider to think through and document needs, questions, concerns, impact on workflow etc. Jumping immediately into EHR vendor demos, without some basic plan in place, will likely result in an inefficient or ineffective evaluation process. Depending on the practice and their experience with buying technology, it is often worthwhile to take a look at planning resources developed by others to get an idea of what to include in the evaluation process. With a bit of searching there are freely available EHR buying guides, buying tips, etc. that can help point a small practice in the right direction.

Once the evaluation process is under way, questions such as these can help a healthcare provider get a feel for whether or not an EHR vendor may be a good partner over time.

  • What is the user-base of the EHR and is it designed for a certain type of user?
  • Is the EHR system cloud-based or on-premise?
  • How have the feature-sets of the EHR changed over the past few years and what changes are anticipated over the next few years?
  • What is the process for evaluating new feature requests? To what degree is the EHR vendor engaging in usability testing before rolling out new features? Does the EHR vendor have a customer advisory board?
  • What is the method and frequency of software updates? How does the EHR vendor minimize disruptions when software updates are required?
  • Where are the EHR software developers located? Are they all full-time employees?
  • What is the EHR vendor’s philosophy on open vs. proprietary standards?
  • How does the EHR function in a mobile environment? Does it use native mobile technologies, or is it more a replication of the desktop experience on a mobile device?
  • How is customer support handled? Are all the customer support staff full-time employees?
  • What types of certifications and credentials are held by the EHR vendor’s staff?
  • To what degree does the EHR system support migration to other systems to avoid vendor lock-in?

Q: What sort of questions should providers be asking their vendors pre-implementation? And what should they be doing on a regular basis after the systems are in place to make sure they're getting the most from them?

A: The research indicates many healthcare provides acknowledge not being fully prepared for their EHR implementation. Additionally, four in ten indicated the EHR implementation was more difficult than anticipated.

Examples of pre-implementation questions:

  • How does the EHR system align with practice objectives?
  • What are the impacts on workflow? To what degree is there flexibility between the EHR system and workflow? Alternatively, does the EHR system support workflow or dictate workflow?
  • The vendor should request input from the full range of users, and not just the person making the buy decision. As noted in the research, staff buy-in is an issue, which can be minimized if everyone feels engaged in the implementation process.
  • What metrics are used to determine success? For example, what metrics are available to assess the implementation itself, was well as longer-term impacts on staff productivity, patient care, reduced errors, etc.?
  • To what degree does the EHR system integrate with other systems? Is interoperability standard, or does it require customizing the systems in some way to allow them to work together?
  • What are the contingency plans? For example, if x unexpected occurs during the implementation, how will the EHR vendor handle it?
  • If the EHR vendor’s system is on-premise, what investments, if any, must be made in networking equipment or other infrastructure?
  • If the EHR vendor’s system is cloud-based, what investments, if any, must be made to ensure fast and reliable broadband?
  • What is the vendor’s disaster recovery and business continuity plan?

Examples of post-implementation questions:

  • Training is routinely mentioned in the research as an area for improvement, so the healthcare provider will want to get a thorough understanding of how training is handled. Is it a quick one-off engagement involving a data dump, or is it modular, allowing for users to digest the material over time? Are there refresher courses? Is there an e-learning option that provides users training flexibility? Is there an online user community that allows for peer-to-peer knowledge sharing? Of course, it’s worth keeping in mind, some users will not want to participate in training (believing they are too busy, it’s unnecessary, it’s boring, etc.), which does put the EHR vendors in a tough spot.
  • How will on-going support be handled? What types of troubleshooting is the responsibility of the users and what is the responsibility of the EHR Vendor. If a cloud-based system, what are the details of the service level agreement?
  • Will the EHR vendor provide a single point of contact (which is ideal), or is the support provided by whomever is available?
  • After certain periods of usage (e.g. 6 months, 12 months, etc.), what metrics will be used to assess performance? Similarly, what is the feedback loop for users? Is there are formal mechanism, such as user satisfaction surveys, that allow users of all types to convey what is working or not working to the EHR vendor?

Q: As these providers make the leap, what lessons (good or bad) should they take from those who have gone before them?

A: The CompTIA research indicates healthcare providers are now more positive and generally more receptive to the EHR transition. Many recognize there will be undoubtedly be some challenges, but the market is moving in that direction and they need to embrace it. Others, eagerly anticipate benefits such as a greater ability to use and analyze data, the reduction of errors or redundancy, and the flexibility that comes with mobile devices and apps and the potential to get patients more involved in managing their own care.

The research indicates segments of EHR adopters underestimating the time and disruption of an implementation. Others acknowledge insufficient staff buy-in and support for the transition. Moreover, few EHR adopters achieve optimal use from the get go. Gains in productivity, efficiency and cost savings take time to achieve.

The lesson: Realistic expectations must be set, and staff at all levels must be part of the process.

[See also: EHR adoption still a top concern for physician practices]