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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 the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manager 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, a role he recently repeated for a Council member.

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, 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.

Doctors: EMRs Can Be Quality Obstacles

Posted on October 15, 2013 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 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.

Many doctors believe that today’s EMRs are difficult to use and stand in the way of quality care at times, according to a new RAND Corporation research report covered by Healthcare IT News.

The RAND report comes from a project, sponsored by the American Medical Association, which was designed to identify what influences doctors’ professional satisfaction.

To research the report, RAND surveyed 30 physician practices in six states–Colorado, Massachusetts, North Carolina, Texas Washington and Wisconsin. RAND researchers also visited each of the practices on site, conducting in-depth interviews with 220 doctors, medical administrators and allied health professionals to see what drives doctors’ satisfaction with their work lives.

One key finding of the report was that being able to provide high-quality care is a primary factor in job satisfaction for physicians — and that anything which hinders them from doing so is a source of stress. And one critical factor that doctors feel impedes their ability to deliver good care is the requirement to use EMRs, Healthcare IT News notes.

Doctors who responded to the survey told RAND that current EMR technology gets in the way of face-to-face discussions with patients, demands that physicians spend too much time on clerical work and lowers the accuracy of medical records by encouraging the use of template-generated notes, according to Healthcare IT News.

What’s more, doctors told RAND that they’re unhappy that EMRs have been more costly than expected, and that the lack of interoperability between various EMRs has been a major frustration, as  it keeps them from easily sending patient data where it’s needed and when it’s needed.

Medical practices are trying to reduce doctor frustration by hiring staffers to perform many tasks involved in maintaining electronic records. And practices are attempting to improve physician satisfaction in other ways, such as giving them more independence in structuring clinical activities and allowing more control over the pace and content of the care they provide.

Still, it’s telling that as many as one-fifth of practices might switch EMRs, searching for an system that solves problems rather than creating new ones.  Whatever practices are doing to help physicians achieve satisfaction with their current EMR, it doesn’t seem to be working very well.

Health IT Doesn’t Save As Much As Hoped Due To Interoperability Failures

Posted on January 14, 2013 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 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.

Does health IT actually save money for health organizations?  That’s a billion-dollar question — one which the whole Meaningful Use program rises or falls, I’d argue — but it still hasn’t been resolved. For what it’s worth, though,  here’s some thoughtful input on the subject.

According to a new study appearing in the journal Health Affairs, always the class act of the health policy game, health IT isn’t generating cost savings because of slow adoption and limited interoperabilityiHealthBeat reports. The research was conducted by the RAND Corporation.

Specifically, RAND researchers say, the productivity and cost benefits of health IT have been held back by:

* Slow adoption
* Reluctance of many clinicians to burn the midnight oil needed to truly master such systems
* Failure of the healthcare system as a whole to implement process changes needed to realize health IT system benefits

Another big issue is lack of interoperability between many health IT systems, the RAND researchers said. They note that previous predictions about health IT savings assumed that systems would be connected, thereby increasing efficiency.

To get savings from health IT, the U.S. healthcare industry needs to do the following, RAND says:

* Patients should be able to access their electronic health data and share those records with other health care providers
* Health care providers should be able to easily use health IT systems across different health care settings
* Health information stored in one IT system should be retrievable by health care providers that are part of other health care    systems
* Health IT systems should be set up to support — rather than hinder — the work of clinicians

No one of these points should come as a surprise, but given the stakes involved, it doesn’t hurt to hammer them home again. The whole interoperability “thing” isn’t going away…