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Current Security Approaches May Encourage EMR Password Sharing

Posted on October 19, 2017 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

In theory, you want everyone who accesses a patient’s health data to leave a clear footprint. As a result, it’s standard to assign every clinician using EMR data to be assigned a unique user ID and password. Most healthcare organizations assume that this is a robust way to document who is using the system and what they do when they’re online.

Unfortunately, this may not be the case, which in turn means that providers may know far less about health data users than they think. In fact, this approach may actually undermine efforts to track health data access, according to a new study appearing in the journal Healthcare Informatics Research.

The researchers behind the study created a Google Forms-based survey asking medical and para-medical personnel whether they’d ever obtained another medical staff member’s password, and if so, how many times and what their reasons were.

They gathered a total of 299 responses to their questions. Of that total, 220 respondents (just under 74%) had “borrowed” another staff member’s password. Only 57% answered the question of how many times this had happened, but among those who did respond the average rate was 4.75 episodes. All of the residents taking part had obtained another medical staff member’s password, compared with 57.5 percent of nurses.

The reasons medical staffers gave for sharing passwords included that “I was not given a user account despite having to use the system to fulfill my duties.” This response was particularly prevalent among students. Researchers got similar results when naming the reason “the permissions granted to me did not allow me to a fulfill my duties.”

Given their working conditions, it may be hard for medical staff members to avoid bending the rules. For example, the authors suggest that doctors will at times feel compelled to share password information, as their duties are wide-ranging and may involve performing unplanned services. Also, during on-call hours, interns and residents may need to perform activities that require them to use others’ EMR account information.

The bottom line, researchers said, is that the existing approach to health data security are deeply flawed. The current password-based approach used by most healthcare organizations is “doomed” by how often clinicians share passwords, they argue.

In other words, putting these particular safeguards in effect may actually have the paradoxical effect. Though organizations might be tempted to strengthen the authentication process, doing so can actually worsen the situation by encouraging system workarounds.

To address this problem over the long-term, widely-accepted standards for information security may need to be rethought, they wrote. Specifically, while the ISO standard bases infosec on the principles of confidentiality, integrity and availability, organizations must add usability to the list. Otherwise, it will be difficult to get an-users to cooperate voluntarily, the article concludes.

What’s Involved In Getting To EHR 2.0?

Posted on September 22, 2017 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

While the current crop of EHRs have (arguably) served a useful purpose, I think we’d all agree that there’s a ton of room for improvement. The question is, what will it take to move EHRs forward?

Certainly, we face some significant obstacles to progress.

There are environmental factors in play, such as reimbursement issues.

There’s the question of what providers will do with existing EHR infrastructure, which has cost them tens or even hundreds of millions of dollars if next-gen EHRs call for a new technical approach.

Then, of course, there’s the challenge of making the darn things usable by real, human clinicians. So far, we simply haven’t gotten anything that solves that issue yet.

That doesn’t mean people aren’t considering the issue, however. One health IT leader that’s stepped up to the plate is Dr. John Halamka, chief information officer of the Beth Israel Deaconess Medical Center and CIO and dean for technology at Harvard Medical School.

In his Life As Healthcare CIO, Halamka lays out the changes he sees as driving the shift to EHR 2.0. Here are some of his main points:

  • Regulators are shifting their focus from prescribing certain types of EHR functionality to looking at results technology achieves. This supports the healthcare industry’s movement from a data recording focus to an outcomes focus.
  • With doctors being pulled in too many directions, it will take teams to maintain patient health, this calls for a new generation of communication and groupware tools. These tools should include workflow integration, rules-based escalation messages, and routing based on time of day, location, schedules, urgency, and licensure.
  • With value-based purchasing gradually becoming the norm, EHRs need new capabilities. These should include the ability to document care plans and variation from those plans, along with outcomes reported from patient-generated healthcare data. Eventually, this will mean the dawn of the Care Management Medical Record, which enrolls patients and protocols based on their condition then ensures that patients get recommended services.
  • EHRs must be more usable. To accomplish this, it’s helpful to think of EHRs as platforms upon which entrepreneurs can create add-on functionality, along the lines of apps that rest on top of mobile operating systems.
  • Next-gen EHRs need to become more consumer-driven, making patients an equal member of the care team. Although existing EHR models do have patient portals, they aren’t robust enough to connect patients fully with their care, and they don’t include tools helping patients navigate their care system.

As far as I can tell, Dr. Halamka has covered the majority of issues we need to address in transitioning to new EHR models. I was also interested to learn that regulatory bodies have begun to “get it” about the limitations of demanding certain functions be included in an EHR system.

I’m still left with one question, however. How does interoperability fit into this picture? Can we even get to the next generation of EHRs without answering the question of how they share data between one another? To me, it’s clear that the answer is no, we can’t leave this issue aside.

Other than that, though, I found Dr. Halamka’s analysis to be fairly comforting. Nothing he’s described is out of reach, unless, of course, vendors won’t cooperate. I think that as providers reach the conclusions he has, they’ll demand the kind of functionality he’s outlined, and vendors will have no choice but to pony up. In other words, there might actually be light at the end of the EHR tunnel.

Say It One More Time: EHRs Are Hard To Use

Posted on September 19, 2017 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

I don’t know about you, but I was totes surprised to hear about another study pointing out that doctors have good reasons to hate their EHR. OK, not really surprised – just a bit sadder on their account – but I admit I’m awed that any single software system can be (often deservedly) hated this much and in this many ways.

This time around, the parties calling out EHR flaws were the American Medical Association and the University of Wisconsin, which just published a paper in the Annals of Family Medicine looking at how primary care physicians use their EHR.

To conduct their study, researchers focused on how 142 family physicians in southeastern Wisconsin used their Epic system. The team dug into Epic event logging records covering a three-year period, sorting out whether the activities in question involved direct patient care or administrative functions.

When they analyzed the data, the researchers found that clinicians spent 5.9 hours of an 11.4-hour workday interacting with the EHR. Clerical and administrative tasks such as documentation, order entry, billing and coding and system security accounted about 44% of EHR time and inbox management roughly another 24% percent.

As the U of W article authors see it, this analysis can help practices make better use of clinicians’ time. “EHR event logs can identify areas of EHR-related work that could be delegated,” they conclude, “thus reducing workload, improving professional satisfaction, and decreasing burnout.”

The AMA, for its part, was not as detached. In a related press release, the trade group argued that the long hours clinicians spend interacting with EHRs are due to poor system design. Honestly, I think it’s a bit of a stretch to connect the study results directly to this conclusion, but of course, the group isn’t wrong about the low levels of usability most EHRs foist on doctors.

To address EHR design flaws, the AMA says, there are eight priorities vendors should consider, including that the systems should:

  • Enhance physicians’ ability to provide high-quality care
  • Support team-based care
  • Promote care coordination
  • Offer modular, configurable products
  • Reduce cognitive workload
  • Promote data liquidity
  • Facilitate digital and mobile patient engagement
  • Integrate user input into EHR product design and post-implementation feedback

I’m not sure all of these points are as helpful as they could be. For example, there are approximately a zillion ways in which an EHR could enhance the ability to provide high-quality care, so without details, it’s a bit of a wash. I’d say the same thing about the digital/mobile patient engagement goal.

On the other hand, I like the idea of reducing cognitive workload (which, in cognitive psychology, refers to the total amount of mental effort being used in working memory). There’s certainly evidence, both within and outside medicine, which underscores the problems that can occur if professionals have too much to process. I’m confident vendors can afford design experts who can address this issue directly.

Ultimately, though, it’s not important that the AMA churns out a perfect list of usability testing criteria. In fact, they shouldn’t have to be telling vendors what they need at this point. It’s a shame EHR vendors still haven’t gotten the usability job done.

Is The ONC Still Relevant?

Posted on July 18, 2017 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Today, I read an article in Healthcare IT News reporting on the latest word from the ONC. Apparently, during a recent press call, National Coordinator Donald Rucker, MD, gave an update on agency activities without sharing a single new idea.

Now, if I were the head of the ONC, I might do the same. I’m sure it played well with the wire services and daily newspapers reporters, most of whom don’t dig in to tech issues like interoperability too deeply.

But if I were wiseacre health IT blogger (and I am, of course) I’d react a bit differently. By which I mean that I would wonder aloud, very seriously, if the ONC is even relevant anymore. To be fair, I can’t judge the agency’s current efforts by what it said at a press conference, but I’m not going to ignore what was said, either.

According to HIN, the ONC sees developing a clear definition of interoperability, improving EMR usability and getting a better understanding of information blocking as key objectives.

To address some of these issues, Dr. Rucker apparently suggested that using open APIs, notably RESTful APIs like JSON, would be important to future EMR interoperability efforts. Reportedly, he’s also impressed with the FHIR standard, because it’s a modern API and because large vendors have very get some work with the SMART project.

To put it kindly, I doubt any of this was news to the health IT press.

Now, I’m not saying that Dr. Rucker got anything wrong, exactly. It’s hard to argue that we’re far behind when it comes to EMR usability, embarrassingly so. In fact, if we address that issue many of EMR-related efforts aren’t worth much. That being said, much of the rest strikes me as, well, lacking originality and/or substance.

Addressing interoperability by using open APIs? I’m pretty sure someone the health IT business has thought that through before. If Dr. Rucker knows this, why would he present this as a novel idea (as seems to be the case)? And if he doesn’t, is the agency really that far behind the curve?

Establishing full interoperability with FHIR? Maybe, someday. But at least as of a year ago, FHIR product director Grahame Grieve argued that people are “[making] wildly inflated claims about what is possible, [willfully] misunderstanding the limits of the technology and evangelizing the technology for all sorts of ill-judged applications.”  If Grieve thinks people are exaggerating FHIR’s capabilities, does ONC bring anything useful to the table by endorsing it?

Understanding information blocking?  Well, perhaps, but I think we already know what’s going on. At its core, this is a straightforward business use: EMR vendors and many of their customers have an incentive to make health data sharing tough. Until they have a stronger incentive share data, they won’t play ball voluntarily. And studying a much-studied problem probably won’t help things much.

To be clear, I’m relying on HIN as a source of facts here. Also, I realize that Dr. Rucker may have been simplifying things in an effort to address a general audience.

But if my overall impression is right, the news from this press conference isn’t encouraging. I would have hoped that by 2017, ONC would be advancing the ball further, and telling us something we truly didn’t know already. If it’s not sharing new ideas by this point, what good can it do? Maybe that’s why the rumors of HHS budget cuts could hit ONC really hard.

Paper Records Are Dead

Posted on March 14, 2017 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Here’s an argument that’s likely to upset some, but resonate with others. After kicking the idea around in my head, I’ve concluded that given broad cultural trends, that the healthcare industry as a whole has outgrown the use of paper records once and for all. I know that this notion is implicit in what health IT leaders do, but I wanted to state this directly nonetheless.

Let me start out by noting that I’m not coming down on the minority of practices (and the even smaller percentage of hospitals) which still run on old-fashioned paper charts. No solution is right for absolutely everyone, and particularly in the case of small, rural medical practices, paper charts may be just the ticket.

Also, there are obviously countless reasons why some physicians dislike or even hate current EMRs. I don’t have space to go into them here, but far too many, they’re hard to use, expensive, time-consuming monsters. I’m certainly not trying to suggest that doctors that have managed to cling to paper are just being contrary.

Still, for all but the most isolated and small providers, over the longer term there’s no viable argument left for shuffling paper around. Of course, the healthcare industry won’t realize most of the benefits of EMRs and digital health until they’re physician-friendly, and progress in that direction has been extremely slow, but if we can create platforms that physicians like, there will be no going back. In fact, for most their isn’t any going back even if they don’t become more physician firendly. If we’re going to address population-wide health concerns, coordinate care across communities and share health information effectively, going full-on digital is the only solution, for reasons that include the following:

  • Millennial and Gen Y patients won’t settle for less. These consumers are growing up in a world which has gone almost completely digital, and telling them that, for example they have to get in line to get copies of a paper record would not go down well with them.
  • Healthcare organizations will never be able to scale up services effectively, or engage with patients sufficiently, without using EMRs and digital health tools. If you doubt this, consider the financial services industry, which was sharing information with consumers decades before providers began to do so. If you can’t imagine a non-digital relationship with your bank at this point, or picture how banks could do their jobs without web-based information sharing, you’ve made my point for me.
  • Without digital healthcare, it may be impossible for hospitals, health systems, medical practices and other healthcare stakeholders to manage population health needs. Yes, public health organizations have conducted research on community health trends using paper charts, and done some effective interventions, but nothing on the scale of what providers hope (and need) to achieve. Paper records simply don’t support community-based behavioral change nearly as well.
  • Even small healthcare operations – like a two-doctor practice – will ultimately need to go digital to meet quality demands effectively. Though some have tried valiantly, largely by auditing paper charts, it’s unlikely that they’d ever build patient engagement, track trends and see that predictable needs are met (like diabetic eye exams) as effectively without EMRs and digital health data.

Of course, as noted above, the countervailing argument to all of this is the first few generations of EMRs have done more to burden clinicians than help them achieve their goals, sometimes by a very large margin. That seems to be largely because most have been designed — and sadly, continue to be designed — more to support billing processes than improve care. But if EMRs are redesigned to support patient care first and foremost, things will change drastically. Someday our grandchildren, carrying their lifetime medical history in a chip on their fingernail, will wonder how providers ever managed during our barbaric age.

 

Don’t Blame Providers For Variations In EMR Use

Posted on June 20, 2014 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

A new study published in the Journal of the American Medical Informatics Association has documented what we all already know  — that providers have idiosyncracies in how they use EMRs. The question that remains unanswered is whether this is a bad thing.

According to iHealthBeat, researchers dug into a massive amount of data which painted a picture of how 112 physicians and nurse practitioners working in federally qualified health care centers in New York City used their EMRs. To conduct the study, the researchers looked at 430,803 visits by 99,649 patients who came to the centers.

After analyzing the data, the study found that providers varied in several key habits when using their EMRs, including how often the updated patient problem lists, when they would respond to clinical decision support alerts, whether the appointment was with a new patient or an established one, and the use of the meaningful use objective metrics, iHealthBeat reported.

Why were providers vary so widely and how they conducted these tasks? Researchers said that there are several reasons for this variation, including the providers overall familiarity with the EMR system, the familiarity with the patient’s medical problems, and workflow differences due to staffing differences at the health centers.

According to the researchers, significant variance among providers’ EMR use suggests that it’s a good idea to measure individual level measures of usage, as such studies might improve research on quality and cost outcomes of EMR use. In other words, the study suggests that variance in EMR usage might lead to positive or negative outcomes, and that standardization — once best practices are determined — might improve outcomes.

The problem with this logic, though it sounds  good on the surface, is that providers are struggling hard enough already to develop routines which make EMRs work for them. And as with any other technology, those workarounds are going to vary depending on who you’re talking about and what they’re trying to accomplish.

I’d argue that while tracking sources of variance in EMR use might have some value in improving outcomes, it’s no excuse to force standardization in professionals’ EMR habits, as long as their overall outcomes are appropriate. What’s more, a push to standardize how providers use EMRs puts the struggle to make them workable on providers, not the vendors whose product quirks are almost certainly responsible for this dilemma.

The bottom line, as I see it, is that while this research is useful, it should raise a red flag on vendors, whose usability levels are still far from where they should be. When you give providers a highly usable, well-thought-out interface to use which suits their daily routines, then it might be time to streamline their work habits. Until then, give  them a break if you don’t want to spark a revolution.

P.S. If you’re curious about what the best thinking on EMR usability is out there, check out this list.

Defining EHR Usability Isn’t for the Timid

Posted on December 30, 2013 I Written By

When Carl Bergman isn't rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com, a free service for matching users and EHRs. For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manger doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst.

Editor’s Note: A big welcome to Carl as a writer on EMR and EHR. He’s been writing guest posts across the Healthcare Scene network for many years, but we’re happy to have him now writing formally on EMR and EHR. You’ll be able to read all of Carl’s past and present posts on EMR and EHR here.

Sometimes it seems that EHRs and usability are like Earth and Mars. Their orbits get relatively close, but they’re never going to occupy the same place and time.

Of course, the two we’re occupied with aren’t cosmic equals. EHRs are specific systems, while usability is, at best, a concept with various definitions. In fact, the closer you get to a definition of usability the less focused it becomes. My late brother used to call things like that, “Far aways.” “The farther away you get the better they look.”

Indeed, most definitions of usability say it’s something that’s useful. Ugh. So, is there any way to bring some clarity to its definition, so it has greater precision?

Doing so, I think, requires not only defining what usability is, but also tackling when it’s not present what’s wrong.

Usability: A Different Definition Approach

Most definitions of usability I’ve seen push the issue off onto use or useful. That is, usability is defined as something that is useable. This isn’t far from using a word to define itself, which was a grammar school no no. It also fails to involve the user’s expectation. I would define it this way:

Usability is the ability of a system to supply a desired result with the minimum necessary information, conditions or steps.

This definition hinges on a user getting what they want expeditiously. Simply put, usability means no unneeded fuss or feathers. As I look at it, usability is to systems what parsimony is to logic. In logic, the simplest explanation that explains the occurrence is the best. Similarly, the most usable system is the one that requires the least effort to supply the correct response.

User Hostile Systems

If I left matters at this juncture, however, I wouldn’t have addressed a major related issue. When a system is user hostile, just where has it gone wrong. Each of us has experienced or heard these tales. You make a simple request and wind up in wilderness of documentation or your options are have everything but what you want.

These are negative examples of usability. It is, however, not enough to just stamp them as such and move on. It’s also important to say exactly where usability fails. To get a handle on these issues, I divide them into three classes:

Class One: Bug. Generally, a computer or software bug is anything that caused a wrong or unexpected response. I take a narrower view. To me, a bug represents a properly designed system that’s incorrectly implemented. That is, the program code fails to carry out the system designer’s intent. For example, you click Print and the system emails your Aunt Edna.

Class Two: Design Failure. In these, the code is OK, but the requirements failed. The classic refrain for these is, “ Yes, that‘s what I asked for, but it isn’t what I wanted.” Fixing these, unlike bugs, requires correcting the requirements and conforming the code.

Class Three: Missing Requirement. Sherlock Holmes in the Silver Blaze mystery had this to say about EHR usability:

“Is there any point to which you would wish to draw my attention?”
“To the curious incident of the dog in the night-time.”
“The dog did nothing in the night-time.”
“That was the curious incident,” remarked Sherlock Holmes.

Nothing is less usable than something that doesn’t exist. It’s not a matter of getting wrong. It’s a matter of not getting it at all.

What makes this a difficult category to apply is the issue of user need. What some users think is fundamental, others may regard as a frill or not necessary at all. Usability, therefore, hinges on neither design nor programming but on policy. However, if policy deems the function important, then its omission is far more serious than the other two categories.

An example. I use a large practice associated with a local medical school. It uses Jardogs’ Followmyhealth (FMH) web portal. It conveniently combines PHR, email and scheduling. I especially like being able to email my PCP. Recently, however, I ran into a class three problem.

FMH lists my PCP and any other of my providers. My PCP suggested I see a specialist for a problem. I went to FMH to find a list of specialists and phone numbers. I got nowhere. I could remove a provider, but not find a new one. I searched FMH’s knowledge base for provider and got 40 hits, but nothing on finding one. I then went through the FMH Patient Guide again without luck. Frustrated, I left the system and went to the practice’s public web site. It had the list. I found the department and number I wanted. Once I got set up, the new provider appeared in FMH.

Wondering if I had missed something, I called support with the problem. The support rep spent several minutes, came back, and confirmed that it could not be done, which surprised him. He agreed they should at least have a link in FMH to search for providers. Whether FMH adds it, of course, is a policy question.

EHR Usability: Is There a Right Path?

Posted on December 9, 2013 I Written By

When Carl Bergman isn't rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com, a free service for matching users and EHRs. For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manger doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst.

The following is a guest post by Carl Bergman from EHR Selector.

Earlier this fall, the AMA sponsored a Rand Corporation study on physician’s professional satisfaction. Based on interviews with physicians in 30 practices, the study covers a variety of topics from workplace setting to quality of care, EHRs and health reform, etc. At the time, the report generated discussion about dissatisfaction in general with EHRs and MU in particular.

Usability, Part of MU?
Overlooked in the discussion was a new and important recommendation on usability. Here’s what is says:

Physicians look forward to future EHRs that will solve current problems of data entry, difficult user interfaces, and information overload. Specific steps to hasten these technological advances are beyond the scope of this report. However, as a general principle, our findings suggest including improved EHR usability as a precondition for federal EHR certification. (Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy, p.142) Emphasis added.

It would be overkill to say that this represents adopted AMA policy, however, it’s not overkill to say that the recommendation is part of a project that the AMA initiated and supports. As such, it is most significant that it recognizes the need to bring some coherence to EHR usability and that the MU system is the logical place to put it.

Changing the Vendor – User Relationship
One commentator who did notice the recommendation was EHR Intelligence’s Robert Green. In his review, Green took a different tack. While agreeing that usability needs improvement, he saw a different way to get change:

Usability remains an enigma in many clinic-EHR vendor relationships because it hasn’t been nearly as important in the recent years’ dialogue as “meaningful use.” But among the competing priorities, usability among physicians and their EHR vendor is a real opportunity to develop shared expectations for a new user experience.

As a patient, I would rather not see the delegation of the “usability” dialogue of EHR to those in the roles of meaningful use certification. Instead, physicians who have spent many years of their lives learning how to “take care of patients” could seize the moment to define their own expectations with their EHR vendor of choice within and beyond their practice. (How connected is EHR user satisfaction to vendor choice?) Emphasis added.

I think these two different paths put the question squarely. They agree that usability needs increased action. Users have gotten their message across with alacrity: all systems fail users in some aspect. Some fail catastrophically. Though some vendors take usability to heart, the industry’s response has been uneven and sporadic.

Where these two approaches differ is tactics. Rand looks at usability, and sees an analog to MU functions. It opts for adding usability to MU’s tests. Green sees it as part of the dialogue between user and vendor.

As a project manager and analyst, my heart is with Green. Indeed, helping users find a system that’s a best fit is why we started the Selector.

Marketplace Practicalities
Nevertheless, relying on a physician – vendor dialogue is, at best, limited and at worst unworkable. It won’t work for several reasons:

  • Nature of the Market. There’s not just one EHR market place where vendors contend for user dollars, there are several. The basic divide is between ambulatory and in patient types. In each of these there are many subdivisions depending on practice size and specialty. Though a vendor may place the same product name on its offerings in these areas, their structure, features and target groups differ greatly. What this means is that practices find themselves in small sellers’ markets and that they have little leverage for requesting mods.
  • Resources. Neither vendors nor practices have the resources needed to tailor each installation’s interface and workflow. Asking a vendor, under the best of circumstances, to change their product to suit a particular practice’s interface approach not only would be expensive, but also would create a support nightmare.
  • Cloud Computing. For vendors, putting their product in the cloud has the major advantage of supporting only one, live application. Supporting a variety of versions is something vendors want to avoid. Similarly, users don’t want to hear that a feature is available, but not to them.
  • More Chaos. Having each practice define usability could lead to no agreement on any basics leaving users even worse off. It’s bad enough now. For example as Ross Koppel points out, EHRs record blood pressure in dozens of different ways. Letting a thousand EHRs blossom, as it were, would make matters worse.

ONC as Facilitator Not Developer
If the vendor – buyer relationship won’t work, here’s a way the MU process could work. ONC would use an existing usability protocol and report on compliance.

Reluctance to put ONC in charge of usability standards is understandable. It’s no secret that the MU standards aren’t a hands down hit. All three MU stages have spawned much criticism. The criticism, however, is not that there are standards so much as individual ONC’s standards are too arcane, vague or difficult to meet. ONC doesn’t need to develop what already exists. The National Institutes of Standards and Technology usability protocols were openly developed, drawing from many sources. They are respected and are not seen as captured by any one faction. (See NISTIR 7804. And see EMRandEHR.com, June 14, 2012.)

As I’ve written elsewhere, NIST’s protocols aren’t perfect, but they give vendors and users a solid standard for measuring EHR usability. Using them, ONC could require that each vendor run a series of tests and compare the results to the NIST protocols. The tool to do this, TURF, already exists.

Rather than rate each product’s on a pass – fail basis, ONC would publish each product’s test results. Buyers could rate product against their needs. Vendors whose products tested poorly would have a strong incentive to change.

EHRs make sense in theory. They also need to work in practice, but don’t. The AMA –Rand study is a call for ONC to step up and takes a usability leadership role. Practice needs to match promise.

Healthcare vs Sickcare, MU Undermines EHR Usability, and Kaiser Monkey Game

Posted on July 15, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.


This might seem a little self serving since I sent this tweet in reply to Georg Margelis’ comment. It’s a really good question though and one I’ve been starting to think about recently. I’ve often heard that the really sick people are the ones that cost healthcare so much money. My question is whether keeping them healthy just delays the costs or whether keeping them healthy actually costs less money long term.


This is such an important topic. I’ve been commenting more and more on this subject. I’ve wondered if a usable EHR can be created that satisfies MU. I imagine it depends on how you define usable.


This is a pretty cool Monkey game from Kaiser. Although, the real value in this article is better understanding some of the approaches that Kaiser is taking to healthcare. So many people salivate over working with Kaiser. It’s good to understand what they are and aren’t looking for if you’re looking for that relationship.

EMR Usability Point Difference, Us vs Them in EHR Adoption, and EMR Companies Don’t Care About Usability

Posted on July 7, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.


I can’t believe there’s a 30 point difference in usability. Really? No, I’m not talking about the difference. I’m talking about trying to put a number on EMR usability. Think how ridiculous that idea really is. An EMR is made up of 100s of functions and you’re going to take an EMR vendor’s usability and try and quantify it to a number. That’s just insane.


This is an awesome point that really highlights a bunch of the key challenges that happen in EMR implementations. There’s definitely a lot of blame and finger pointing that can happen. You have to battle against this for it not to happen.


This is a great article that can be summed up with: because they don’t have to care. That’s right. EHR sales are doing just fine, so they don’t have to worry about usability. Healthcare really has reached a point of acceptance of crappy technology. This will change one day, but I don’t see it changing at least until after meaningful use.