It’s Just Easier to Insist on Excellence Before Buying the Product, A Behind the Scenes Story

Posted by Michael on January 15, 2013

By Nicholas Genes 

For much of the past two decades, physicians, administrators and health IT experts offered explanations why hospitals and practices stuck to their old, disjointed, largely paper-based systems for patient care, and refused to adopt electronic health records. While benefits of EHR seemed clear, the lack of adoption was explained through a combination of high costs of implementation and maintenance, difficulty guaranteeing security and privacy, and concerns about usability – namely, the fear that EHR implementation would have a disruptive effect on efficiency and workflows.

That usability should be a concern of EHR software is perhaps a little surprising, as computers by themselves generally have a reputation for improving efficiency. Furthermore, functional, elegant software design has become a major priority for web applications, document managers, and mobile operating systems.

But part of the problem might be that, for the average user, usability can be hard to define – it takes some thought to offer more than Justice Stewart’s comment (on the topic of obscenity), “I know it when I see it.”

It was only in the 1990s that Jakob Neilsen published his Ten Usability Heuristics. These heuristics are so simple, it’s a wonder they need to be enumerated, such as:

  • “Speak the user’s language, with words, phrases and concepts familiar to the user, rather than system-oriented terms.”
  • “Users should not have to wonder whether different words, situations or actions mean the same thing.”
  • “Every extra unit of information in a dialogue competes with the relevant units of information and diminishes their relative visibility.”

Yet most physicians who’ve adopted EHR can rattle off examples of how their systems fail at these simple guidelines. Overly verbose pop-ups, for instance, disrupt concentration and obscure the relevant information. Items in some windows require a single click to select, but in other windows, double-clicking is necessary. And, most distressingly, medication orders and lab results are usually displayed in vendor-specific ways, far different from the conventions we learned in med school.

How did this come to pass? EHR software vendors began, in many cases, as billing software vendors. With time, they expanded their offerings to include lab and radiology result reporting and ordering, and then eventually, clinical documentation. Features were added haphazardly to compete on contracts or appease clients. Healthcare institutions demanded the latest versions of software, but didn’t want to re-train their personnel to new workflows. Viewed in this light, it’s not surprising that EHR software, growing haphazardly to take on disparate roles, struggling to maintain backward compatibility, would become confusing and inconsistent to use.

So it’s not surprising that, upon adopting EHR systems, many clinicians and hospitals report an “efficiency hit” – taking longer to do the same tasks, causing delays in care and patient throughput. The ROI for EHR has proven contentious to calculate, and whether patient outcomes improve with EHR is similarly controversial and location-specific.

And yet, despite this poor usability, large-scale EHR adoption is finally happening in the US, spurred mostly by financial incentives derived from the 2009 stimulus. Hospitals and practices are rewarded an increased fraction of Medicare and Medicaid reimbursements, if they demonstrate to CMS that they’ve achieved “Meaningful Use” of EHR. Every so often, the criteria for demonstrating meaningful use expands – this year, it means incorporating health information exchange with other institutions, or a portal for patients to log in and view results, among other requirements.

It’s been suggested that future iterations of meaningful use criteria include some standards of usability. One might imagine that incentive dollars would be withheld, for instance, if the installed EHR displayed medications inconsistently. Indeed, NIST – the National Institute for Standards and Technology – recently began to build consensus between vendors, federal stakeholders, and physicians on what standard should be sought for EHR usability.

The NIST guidelines, released earlier this year, focus on reducing errors in EHR – an understandable goal for a federal agency. If these guidelines are eventually incorporated into meaningful use criteria, however, an opportunity would be missed, as many MU goals already focus on patient safety, and there are other aspects of EHR usability in need of attention.

There’s another hope for usability, however. Now that EHR adoption has become widespread, frustrated physicians - and patients, dismayed by their doctor’s diverted attention - may simply demand better software. We’re all savvier shoppers now, and more acquainted with what makes software usable.

It’s just easier to insist on excellence before buying the product.