The HITECH Act resulted in near universal adoption of electronic health records (96 percent in hospitals and nine out of ten physician offices, according to the latest ONC tally) and having all that clinical information in electronic form is a remarkable advance.
It enables a wide range of possibilities for improving care, assessing its value, and managing populations in ways that might actually improve our collective health and reduce the overall healthcare bill. On the most basic level, caregivers should have an easier time getting up to speed on each patient's history and current condition than in the old days where they had to thumb through a paper chart trying to decipher other physicians' handwriting. Moreover, this advance means that patients can become more active and equal participants in their care; they can use their phones to discuss healthcare issues with their care team and see when they last had a tetanus shot.
But this significant progress in adoption also gave rise to concerns about the usability of EHRs.
Physicians are spending twice as much time with their EHRs as they do with patients, according to a time and motion study published last fall by the AMA. In the most recent Medscape Lifestyle Report, a survey of 14,000 physicians, EHRs were the fourth most common cause of burnout EHR complaints beat out insurance issues, threat of malpractice suits, concerns about salary, and patient volume.
EHR-induced patient safety problems related to usability are becoming a concern. A 2015 study published in the Journal of Patient Safety described almost 250 cases where EHR glitches or poor human factors were alleged to have caused patient incidents led.
Why have usability issues come to dominate so many discussions about EHRs?
First, change is hard, and EHRs are a big change, especially for clinicians who spent decades perfecting their use of paper charts. Any time you introduce new technology and new processes deep into the fabric of someone’s work routine, there will be significant struggles and bumpy transitions that might last years.
Second, if you're used to whipping off a prescription in five seconds, spending thirty seconds to enter the same information into the computer must seem like an absurd imposition, even if it does make the information exquisitely readable and simultaneously accessible to all authorized users. The same is true of many formerly paper-based tasks that now require clinicians to enter structured terms into fields. Those extra few seconds per task, multiplied by dozens of tasks, can add hours to the workday.
Third, the user interface design of EHRs can be sub-par. Compared with the smartphone tech we carry in our pockets, many EHR user interfaces feel like a throwback to the 1990s, and too many clinicians have tales of needing a dozen clicks to order a single drug, or being harassed by alerts to the point where they just ignore them all.
In fairness to EHR developers, automating healthcare tasks presents an exceptionally difficult design challenge. Medicine is based on a very complex body of knowledge, encompasses dozens of specialties, and tackles thousands of different diseases. Ideally it requires an application that can aggregate patient histories, lab values, medical images, monitor tracings, vital signs, progress notes, and miscellaneous other pieces of information, process them, analyze them, and send them back to the clinician with notes on best practices and relevant recent research. Compare that task to designing an application that supports the six transactions we might want to make at an ATM.
Fourth, in our collective efforts to improve care we have moved more and more work onto the shoulders of the clinician. Asking patients about the safety of their homes, engaging them in discussions about smoking cessation, counseling them about the importance of taking their medications, and documenting interactions using structured vocabularies – all of these actions could benefit patients. But their cumulative impact on a clinician can be overwhelming.
In some ways, beating up EHR vendors on usability is a form of shooting the messenger. Clearly the vendors have work to do, but others created the tyranny of large numbers of good ideas of work for the clinician.
What’s more, physicians often don't directly benefit from investing all this extra time. It's legitimate for them to ask, "What's in it for me and my patients?"
The benefits of EHRs seem to accrue to the healthcare system as a whole, or to payers--not to physicians, unless their compensation is adjusted.
Eventually, a value-based reimbursement model should reward their effort, but that prospect probably seems very far away to most.
So, what can we do to significantly improve the usability of electronic health records? There is no single strategy or tactic that will address all these factors.
We can make significant strides with a multi-faceted approach:
Policy: We must continue our efforts to move to value-based reimbursement. Not only is this model good for patients, it will help us focus on what information we really need out of our EHRs in order to assess value and identify ways to increase it.
We can give clinicians appropriate incentives by basing their compensation on outcomes so that they see a clear reward from using the EHR to ensure that their care follows the evidence.
We must continue to work with CMS, state Medicaid programs and private sector health plans and purchasers to focus on changing reimbursement, so that those who are doing quality work see a reward for their efforts.
We should strive to rationalize and coordinate the demands for quality measures and documentation so that our clinicians don't have to jump through multiple hoops with data entry in order to report essentially the same piece of information to multiple places.
We must also push for national usability standards and industry-wide efforts to improve our knowledge of best usability practices. The 14 basic principles laid out by the American Medical Informatics Association in 2013 were a great start. Keep your eye on this initiative out of the National Institute for Standards and Technology, and the usability framework being developed by the American Medical Association and MedStar Health’s National Center for Human Factors in Healthcare.
We should support EHR safety improvement efforts such as those being advanced by the National Patient Safety Foundation and the ECRI Institute.
Products: Providers must keep the pressure on their vendors to explore ways to smooth the collection of information and review of results. Context-aware software can whittle down choices to a manageable number so that users don't have to scroll through dozens of options every time they need to enter an order. Advanced data visualization can help users focus on the most important information and correctly interpret that information.
Natural language processing is already making amazing progress at interpreting free text and pulling out individual data elements. It can potentially liberate clinicians from clicks and pull-down menus entirely. Combined with advanced voice recognition, it could even save them from typing.
Beyond these innovative technologies, providers should also insist that their EHR vendors take advantage of the wealth of knowledge about best user-centered design practices. EHR vendors can learn from other industries and from consumer-oriented technologies.
Process: While we are busy working to improve policy and products, we can also make usability gains by improving our clinical and operational processes.
Consider technologies that allow you to compare how your clinicians use your EHR. You may find that one physician is taking five clicks and eight seconds to complete a task, while another is taking seventeen clicks and thirty seconds. Understanding why these differences exist can point to supplementary training needs and additional changes in workflow.
Look for ways to distribute the EHR-related workload. Some tasks can probably be taken off the physician’s shoulders and given to other members of the care team, or even to the patient. Some organizations have approached this distribution using scribes, who follow physicians around and enter the data for them. The American College of Medical Scribe Specialists projects that there will be 100,000 active scribes by 2020, roughly a five-fold increase over current levels. That's about one for every nine doctors.
Finally, healthcare executives and clinicians need to keep educating themselves. Every widely used EHR has some customers that show high adoption and satisfied clinicians. They will be popular speakers at industry and user group meetings. Find out their secrets and steal them. Organizations can also learn from themselves. It's crucial to have an open, candid, and ongoing internal dialogue about what's working and what isn't.
Our national efforts to improve health and healthcare will rely on a solid base of electronic health records that are used well and materially assist the efforts and knowledge of caregivers and the patients. Advancing EHR usability is not impossible, or even particularly mysterious. But it is complex and it won't happen by itself. We must keep the pressure on our policymakers, our vendors, and ourselves.
John Glaser, Ph.D., is Senior Vice President, Population Health, of Cerner Corporation. Prior to this position he served as the Chief Executive Officer of the Health Systems Business Unit at Siemens. He is the author of several books including “Glaser on Health Care IT” published by HIMSS Books.