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Monday / March 8.

The EHR: From Disillusionment To User-Centric Design

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 included incentives and penalties for the adoption of the electronic health record (EHR). Instead of paper charts filled with frequently illegible doctor’s notes, the patient’s hospital care would be documented in clear and crisp type. Laboratory and radiology reports would be imported into the record and would be available at multiple care sites. The advantages seemed enormous and hopes were high.

“We have the capacity to transform health with one thunderous click of a mouse after another,” Michael Leavitt, the US Secretary of Health and Human Services, said at the time.

Instead, those “thunderous” clicks quickly led to physician disillusionment.

The first issue was the clicks themselves. They robbed time better spent with the patient or discussing the case with other providers. According to Health IT & CIO Review:

Emergency department physicians spent 44 percent of their time entering data into electronic medical records, clicking up to 4,000 times in a 10-hour shift.

Robert Wachter, in his book The Digital Doctor, notes that the demands of EHR documentation caused “electronic siloing.” To complete their documentation, doctors and nurses retreated to their “own corner of the department” or were “just inches away from each other, staring at their computers without exchanging a word” – a marked contrast to “the pre-digital days” when “the nurse and the doctor lived and breathed teamwork.”

In addition to the thousands of clicks and decreased patient and clinical team interaction, the EHR “lobotomized” the physician’s progress note. Following the adoption of EHRs at Northwestern Memorial Hospital in Chicago, progress notes were “rendered incapable of conveying useful information by their bloated and obfuscated nature.”

Not surprisingly, the EHR became “a towering source of physician dissatisfaction” with the “wellsprings of discontent” including but by no means limited to “poor usability, time-consuming data entry, interference with face-to-face patient care, and degradation of clinical documentation.”

Some physicians resorted to scribes. Wachter observed:

“Only in healthcare do we bring in computers, and then hire extra people to use them.”


Lack of Focus on the Customer & Bad Design

According to John Patrick in Health Attitude, the EHR was “a technological imperative” developed to “reduce costs, enhance healthcare quality, and improve patient safety.” Unfortunately, major EHR vendors responded to this imperative by developing EHRs on legacy systems.

For example, both Meditech and Epic created their EHRs on the MUMPS programming language, which was originally developed in 1966 – 24 years before MacOS popularized the graphic user interface.

In contrast to the transformation from film-based to digital medical imaging – the most successful digital transformation in healthcare – no universal standard for EHR design was developed.

Furthermore, “the remarkable level of clinical dissatisfaction” generated by EHRs has been attributed to “bad design.” Among Wachter’s critiques is the EHR’s rigidity. Although room for freeform text is usually provided, the mostly checkbox approach limits documentation of a case’s nuances and turns the record “into a desiccated wasteland, devoid of thought or narrative arc.”

Wachter identifies other design flaws in the EHR including difficulty in intuitively navigating the patient’s record and “endless scrolling required to find information.” Drop down menus “missing essential options or offering irrational ones” and identical icons sometimes representing different actions often led to dysfunctional navigation. Eye contact with the patient, so important to building a trusting relationship, was also impacted as the doctor often turned away from the patient while documenting.


Renewed Hope at HIMSS16

One might assume that physician satisfaction with EHRs would increase over time as physicians adjusted to their quirks. However, a survey of 940 physicians conducted by the American Medical Association (AMA) and American EHR Partners in 2015 showed otherwise: satisfaction – at 61% five years before – had dropped to 34%.

Fortunately, several presenters at HIMSS16 held in Las Vegas a few weeks ago recognized EHR design as a significant limitation.

Karen DeSalvo, M.D., the Acting Assistant Secretary for Health in the U.S. Department of Health and Human Services, discussed a proposed rule designed to “enhance the safety, reliability, transparency, and accountability” of health information technology.

Acting CMS administrator Andy Slavitt further noted the rule would promote “user-centered design” in EHR development. Significantly, Slavitt acknowledged that physician disillusionment with the EHR is primarily related to design that “often hurts rather than helps physicians,before sharing one of the several hundred physician EHR related complaints he has received:

“To order aspirin takes eight clicks on the computer. To order double strength, it takes 18.”


User-Centric Design and Increased Patient Safety

“Accidents and oversights aren’t just unintended consequences. These are patients’ lives.” (Trish Lugtu)

While current dissatisfaction is a crucial issue and likely contributes to the ninety percent of physicians who would not recommend a career in medicine, an even deeper concern is patient safety. Patient harm due to EHR-related factors is the result of “unsafe use” or “unsafe technology,” including “incorrect system or software design.”

At HIMSS16, Trish Lugtu, Associate Director of Research at MMIC Insurance Inc., advised the creation of system design and configuration protocols and joint decisions making:

“Both clinicians and health IT people need to be at the table. The IT people don’t understand the intricacies of patient care, and the physicians feel intimidated by the technology, but they need to be communicating.”

By focusing on the customer, user-centric design should lead to increased satisfaction with the EHR. Inclusion of analytics software should help empower the physician. New input technologies such as Augmedix’s Google Glass “wearable, non-interrupting technology” should reduce the tedious and time-consuming clicks and allow the physician to look at the patient instead of the computer during the interview.

Most importantly, development of an intuitive user-centric design should redirect the physician’s mental focus away from rule-based data entry and back to patient care and safety.


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