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Besides the importance of physician happiness when using an EHR, using design principles that maximize user intuition and presentation of relevant information, there is one aspect of health care information systems that should never be overlooked…patient safety.

Scot Silverstein, MD, blogging at Health Care Renewal as InformaticsMD, frequently brings to light issues surrounding health care IT implementations that compromise patient safety.  Reading his posts should be sobering and concerning to both medical professionals and the public alike.  Like I’ve said, health care IT, in my opinion, is still in its infancy despite the number of years computers have been around and the existence of Meaningful Use legislation.

As a practicing physician as well as a software coder, I’ve used a number of EHR’s (and still currently using a well known EHR by my employer of my part time job) to know how some of these appalling user interfaces affect not just workflow and user happiness, but patient safety.

An example of one design element that most physicians may not be able to identify, ironically, is the one that is most harmful when it comes to patient safety. In this well known EHR, you are presented a medication list for a patient. As a physician, you assume that this list is a current medication list and is up to date.  However, the reality is that this EHR system automatically removes a medication from the list when it is determined to be expired even if it should be appearing on the current medication list.

When a physician prescribes a medication from this system, it calculates the duration of usage of the medication based on the instructions, quantity of medication prescribed, and the number of refills. Once the duration exceeds the number of days that has elapsed since the prescription was made, the medication is taken off the current list automatically by the EHR. Now, taken at face value, this sounds like the logical approach to manage a medication list and utilizes the computing power that an EHR will gladly show off as a benefit to physicians.

Unfortunately, the EHR programmers failed to understand that medications are not taken regularly by all patients all the time. In fact, no physician assumes that at all. So why should an EHR make that assumption? Furthermore, there are plenty of treatments that are to be taken only as needed so how can an EHR account for that? Absolutely, impossible.


So I recently treated a patient that reportedly has asthma. I happened to look at a previous note and find out that the patient was denied a refill request for Albuterol, a bronchodialator that is meant to be taken as needed. She ended up in a life threatening asthma flare up and needed emergent care. It turns out the physician on call who was given the refill request several days prior didn’t realize that the EHR removed the Albuterol from her list and subsequently instructed that the patient needed to have a physician visit for having the medication prescribed. After going through 2 different windows and unclicking a check box, I was able to identify that the patient did in fact have an active prescription for Albuterol, but the EHR made it disappear. She has used it infrequently, probably because her asthma was well controlled. Unfortunately, she ended up in worse shape when she needed the medication the most.

Most physicians don’t have the time nor the technical know-how to peer through a complicated EHR. Perhaps I normally don’t trust the EHR because I’ve be jaded by bad designs and because I know how to hack around a system when a bad design didn’t give me the information that I want. But this example highly illustrates that a poorly designed EHR that has not gone through a reality test with a practicing physician leaves patient safety in harms way. I ultimately find it appalling that physicians are being peddled multi-million dollar systems that have not had any real practicing physician input in how these systems are designed.

We are beginning to see studies that question the effectiveness of EHR’s when it comes to health care cost reduction and patient safety. One should not make a general conclusion that all EHR’s don’t help, are a waste of money, and have no place in health care. What gets lost in the translation is that an electronic health record system is not the same from one system to an another. Some do a better job than others. What doesn’t get studied is how physician directed user design can affect these results.

From other industries where user design is absolutely paramount, including automobile and airplane ergonomics as well as smartphone operating systems and their apps, we know how improved and user informed design makes all the difference in terms of quality output by the user. It’s all about using the right tools for the job. If it can be used intuitively, reliably, and repetitively, you have the right tool for the job. Right now, most EHR’s are like sledgehammers when what we really need are sharp chisels that create works of art.

Michael Chen, MD is a family physician in Portland Oregon  as well as a developer and consultant for his own open source electronic health record system called the NOSH ChartingSystem.  He blogs regularly at http://noshemr.wordpress.com, where this post originally appeared.

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25 Responses for “Why EHR Design Matters”

  1. Perry says:

    Nice article Michael, and very good points. I don’t use an EHR right now because I don’t have to. I am hoping that if I ever do, someone has come up with a very good user friendly system for PHYSICIAN use. Right now it appears that most EHRs are set up for coding and billing purposes and to qualify for MU, which now I’m hearing most systems aren’t up to speed for Stage 2 MU anyway.
    While the concept of EHR is good in theory, there is a huge difference in practice, especially when you need to satisfy requirements of the government, insurers, physicians and patients.
    Maybe some day someone will get it right.

    • Paul says:

      You are so right on in that all EMR’s are not created equally! Most I have seen tend to justify their existence by having a voluminous record, which makes it nearly impossible to find the really important data and information. They tend to make the patient encounter longer and more impersonal. I have seen a record from a simple ER visit consume 25 pages! And then, different systems don’t “talk” with each other, making enhanced inefficiency. In theory, EMR sounds good to the politicians, but many “bugs” have to be worked out.

    • Curly Harrison, MD says:

      Contributing to the dumbing of health care workers, especially nurses, EHRs result in errors that never would have occurred under the systems of care being replaced. Nurses have no idea what drugs do that they are clicking on. They are thoughtless servants of the computer.

  2. Any EMR designed to work in an anti-physician CPT/ICD 9-10/MU 2-3/HIPPA/P4P/med mal/coding for dollars medical system will be, by definition, anti-physician and unusable.

    End of discussion.

    • pcb says:

      Yes, yes, and yes.

      EMR designed to satisfy 3rd party interests satisfies 3rd parties and not patients and physicians.

      • Ron says:

        So pcb what do you suggest in moving forward?

        If you were the National Coordinator for Health IT, what would you do?

        Ron

        • pcb says:

          The National Coordinator for Health IT, in our current system, would have to serve CPT /ICD /P4P/MU, etc.

          What I would suggest is finding a different system. One that serves the patient and not the above entities. (direct care or other models outside the 3rd party shackles)

  3. john irvine says:

    Fair enough. PCD

    Well, then what would one that was designed to work in a “doctor-centric” way look like? Here are a few bullet points I’ve come up with

    - information “volume” controls – as much or as little as I need.
    - visual instead of popup, menu driven
    - user configurable – works the way you do, not the way somebody thinks you do
    - limits silos and tunnels

  4. Ron says:

    To be the devil’s advocate a bit:

    Why should EHR vendors, least of all Epic, Cerner, Meditech, GE, Siemens, McKesson or Allscripts, care about the usability of their systems when nearly every institutional customer has already invested a gazillion dollars in them..training staff on them…custom interfacing them, etc.?

    And they can claim any issues with usability of the systems were caused by health system implementation choices. And they can block public sharing of issues or problems caused by their systems (Dr. Chen – what system do you use that has the safety problems that you describe?).

    Think X health system is going to scrap their massive investment in Epic just because users hate it and go out on a limb and purchase something from a plucky, innovative start-up?

    EHR usability sucks. It places safety at risk and harms productivity. We (users) know it. They (the vendors) know it. But the money’s spent. And the government’s not going to declare HITECH a fiasco and get more money for a do-over.

    The question is: What are the concrete steps (and by whom) to move forward in a way that ensures safety, makes users happy and productive and achieves the promise of health IT?

    Ron

    • Ron,
      To answer your question about what system I’m referring to, it’s actually Epic. I totally agree with your comment that these big EMR vendors have no incentive to improve usability and safety because all the money from MU has already established their clout and market share. There is no incentive for health care systems that already use them to switch to something new and innovative. The horse is out of the barn on that one. I argue that even though these systems appear to be entrenched, there may still be an avenue where actual physician users can really take part and demonstrate an alternative EHR design and build process where users and patients really matter (and taking out the middlemen). The way forward is a community-driven process, and in software terms, there is no other framework other than open-source that truly fosters this type of process. Hence my NOSH ChartingSystem project. It’s not an overnight solution, but it’s a start. It’s already built and is used by some independent outpatient clinics. To me, there is so much more potential as more users and developers who care about usability and safety take part in having these discussions and putting them to the test in a software product that is not constrained by licensing fees and closed code.

      • Ron says:

        As important as physicians (and other users) are in providing input, there are no shortage of EHRs on the market that were designed and developed by physicians – and many of them are just as jumbled, unusable, written in arcane languages and otherwise deficient as ones designed by software engineers.

        What’s WAS missing in the development and IS missing in the deployment of EHRs is application of the science of human factors and user-centered design, especially in rigorous ways.

        Human factors has resulted in great improvements in the safety and reliability of everything from aircraft to nuclear power plant displays.

        The IOM, HIMSS and ONC have recognized the important role that better application of human factors could have in improving the safety, efficiency, effectiveness and satisfaction of users on EHRs.

        Yet formal application of UCD remains nascent and poorly understood and resourced by vendors and healthcare providers alike.

        Want to better understand whether your implementation of Epic can result in safety issues related to usability? Use this:

        http://www.himss.org/ResourceLibrary/ResourceDetail.aspx?ItemNumber=10521

        • Bobby Gladd says:

          ‘What’s WAS missing in the development and IS missing in the deployment of EHRs is application of the science of human factors and user-centered design, especially in rigorous ways.”
          __

          I argued with ONC ’til I was hoarse for the inclusion of both usability criteria and QMS in the Stage 2 MU Certification. They ignored the former, and made the latter laughably optional, i.e., if you develop your systems under a quality management system, fine, note it in your CEHRT app. If you don’t, fine as well.

          I mocked this stupidity on my Clinic Monkey EHR site:

          http://4.bp.blogspot.com/-rFvT3zRmT2w/UQlEMqK4MsI/AAAAAAAAis0/xXuoaMfnQAA/s1600/170.314.g.4.jpg

          • Ron says:

            That link haunts my dreams, Bobby!

            That having EHR vendors report the results of their usability tests on medication-related functions was so controversial speaks volumes about this industry and its capacity to address safety without the government forcing it to.

            Vendors were successful in being able to block having to conduct testing on the same, NIST-developed protocol (http://www.nist.gov/manuscript-publication-search.cfm?pub_id=909701) and instead do testing in whatever way they chose

  5. Cramming features into an EHR or other clinical IT systems does not make them “better.”

    EHRs need tremendous simplifications in the clinician documentation portions – “template madness” has to stop; free text and narrative has to reign supreme.

    The kind of behavior you describe – an EHR discontinuing meds by a simplistic formula clearly lacking even med student input – could have caused injury or death. Whoever designed that was, quite simply, an idiot.

    I ask this: if that occurs, should not the designers, sellers and purchasers be subject to liability for negligence?

    • Ron says:

      Why haven’t there been more (any?) successful cases against EHR vendors or healthcare organizations for faulty EHRs or other health IT?

      • Rob Tholemeier says:

        HCOs tend to sign software contracts that have hold-harmless clauses for the vendors. Not so in any other industry we know of. We have an article on this very topic. Providers also sign overly constraining NDAs.

        Good idea to bring in a third party with software contracting experience to review contracts. Some of these folks work on getting better deals and will work on a contingency fee basis.

  6. Whatsen Williams says:

    https://www.accessdata.fda.gov/scripts/medwatch/

    You describe a design flaw that puts patients at risk.

    I recommend that you report it to the FDA.

  7. Chad Sloan says:

    Great article Michael! The conversation that has ensued has provided for major discussion and consideration of the question ‘what do we do now?’ Large EHR software providers are entrenched with healthcare organizations across the country, who in turn are taking advantage of MU government rebates. I believe Michael you bring up a good point for your Open-Source NOSH EHR system as a means to begin shifting the possibility that a system can be created that is actually usable by physicians, nurses, and health IT teams.

    The current situation however, I believe, requires more immediate help in the form of workflow, and rules technology. This growing market seems to be recognizing (at least in some part) the major struggle of EHR systems. Workflow platforms have the ability to manage EHR technologies in conjunction with other hospital systems (i.e. laboratory, ER, Payroll, Patient Medication Management tools, etc.) and seek for a goal of interoperability between these systems. As we see interoperability increase between systems using these software technologies, I think an EHR’s effectiveness in regard to patient safety might increase.

  8. Paul says:

    EHR’s are problematic in many ways….Michael Chen’s excellent piece details one common flaw….others inclue difficulty with the learning curve for physician data entry chews up time and creates gaps in the record…not to mention different venfor platforms don’t interface/translate well. This whole mess of EHR’s is induced adoption before technical viability…it is costly and dangerous for patients.

    But all the above problems will be solved over time…but that bigger issues exist even with a perfectly functioning EHR. My view is that EHR’s are fundamentally flawed. Patients are (and should be) concerned about what they tell their doctor as who really believes privacy reassurances? Drug use, sexual activity, mental health symptoms will not be shared with their doctor. Secondly, EHR’s will be tools for bureaucrats (government and insurance company) to monitor and seek to control the clinical judgement of physicians and other providers. If you choose to treat a patient in a way that varies from the latest iteration of practice guidelines you as a doc will be questioned and perhaps even punished with forgone bonues…or worse. The centrality of the patient doctor relationship is being changed in fundamental ways.

  9. Teame Tilahun says:

    it is a nice article Michael,
    I also agree that if an Interactive health communication application (such as EHR) is designed to achieve maximum usability , it has huge positive impact on managing health care service demands such as reducing medication errors, increasing safety of patient, improving efficiency and happiness of the physician, improving quality of documentation and patient records and so on. On the other hand as you mentioned in your post, if these applications are misused or failed to consider certain situational and organizational factors, their negative impact will be worst. Therefore Such systems have to be designed carefully to ensure quality of care and safety while keeping the effectiveness and accuracy but how?
    One way of improving patient safety and physician’s effectiveness is to enrich the user (patient) and physician interaction. However developing this kind of enhanced interaction needs understanding of human cognitive processes in information gathering, processing and storing. Especially for the designer it is important to know that many users have different potential characteristics of using a certain application in different contexts such as time place, situation, environment and organization. Thus before the design, analyzing and examining the situational, organizational and environmental factors of average users(patient, physician,..) can improve usability of these applications.
    In addition to supporting enhanced patient physician interaction, the human computer interfaces must also receive and respond information in multimodal way such as visual, auditory and haptic so that the user can be notified about the changes he/she made. The interface must also support the feature of changing its behavior (adapt to user preference, ability and situations). In this way the human and computer interaction can be effective and the overall health care service delivery with such applications can be improved.

  10. Paul says:

    From today’s (Jan. 8th, 2014) NY Times:

    Report Finds More Flaws in Digitizing Patient Files

    By REED ABELSON and JULIE CRESWELL

    Published: January 8, 2014

    I tried to link it here but it did not work. You can get to it from drudgereport.com where it is linked. Here is a quote:
    “But the rapid, vast metamorphosis in health care — like transformations of industries before — has been difficult, expensive and controversial. Hospitals have spent tens of billions of dollars buying systems that many have discovered are complicated to use, and critics have raised serious concerns about both patient privacy and safety. A study released last fall found that emergency-room physicians in a community hospital spent 43 percent of their time entering data, clicking up to 4,000 times during a 10-hour shift, compared with only 28 percent directly caring for patients.”

  11. Miklos Auber says:

    EHR’s are problematic in many ways….Michael Chen’s excellent piece details one common flaw….others inclue difficulty with the learning curve for physician data entry chews up time and creates gaps in the record…not to mention different venfor platforms don’t interface/translate well. This whole mess of EHR’s is induced adoption before technical viability…it is costly and dangerous for patients. The current situation however, I believe, requires more immediate help in the form of workflow, and rules technology. This growing market seems to be recognizing (at least in some part) the major struggle of EHR systems. Workflow platforms have the ability to manage EHR technologies in conjunction with other hospital systems (i.e. laboratory, ER, Payroll, Patient Medication Management tools, etc.) and seek for a goal of interoperability between these systems. As we see interoperability increase between systems using these software technologies, I think an EHR’s effectiveness in regard to patient safety might increase.
    http://www.medicalbillingservices.cc

  12. With an EHR, ease of use is an incredibly important factor. Not only does it help physicians streamline their processes, but it can improve accuracy. For example, EHRs that use data generated by mobile dictation applications oftentimes are seamlessly linked with appointment information, ensuring that the right dictation is associated with the right patient.

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