An Open Letter to Dr. David Blumenthal

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Below is a slightly expanded version of a letter I recently sent to Dr. Blumenthal, the new National Coordinator for Health Information Technology, and the members of the new national HIT Policy Committee.

Dear Dr. Blumenthal:

I am writing to you on the need for user-friendly electronic health record (EHR) software programs.  As a practicing physician with first-hand experience with hard-to-use CCHIT-certified EHR software, I would like to share with you a solution to this vital issue.

The CCHIT model for EHR software certification is fatally flawed because it mandates hundreds of required features and functions, which take precedence over good software design.  This flawed CCHIT model takes valuable physician time and effort away from patient care and leads to increased potential for errors, omissions, and mistakes.

As a clinician, I have had first-hand experience with a top-tier CCHIT-certified EHR.  Despite being computer literate and being highly motivated, after a year and a half of concerted effort, I still cannot effectively use this CCHIT-certified program.  The poorly designed software constantly intrudes on my clinical thought process and interferes with my ability to focus on the needs of my patients.

Just this year the National Research Council report on health care IT came to a similar conclusion. The report found that currently implemented health care IT programs often

provide little support for the cognitive tasks of the clinicians or the workflow of the people who must actually use the system.  Moreover, these applications do not take advantage of human-computer interaction [HCI] principles, leading to poor designs that can increase the chance of error, add to rather than reduce work, and compound the frustrations of executing required tasks.

Our health care system needs user-friendly EHR software, firmly grounded on what we have learned about how the human brain takes in, organizes, and processes information.

As an example of software based on usability principles, I would like to share with you a new design, the EHR TimeBar, which is one example of user-friendly EHR software design that can dramatically improve patient care.  Please see attached figure and description at the end of this letter.

I have no financial interest in this software design. My goal is to promote the emergence of user-friendly EHR technology that will improve the day-to-day lives of my colleagues and help us take better care of our patients.

We absolutely need standards for data, data transmission, interoperability, and privacy. There is no need, however, to specify the internal workings of EHR software. To do so will stifle innovative software designs that could improve our health care system. If CCHIT is allowed to mandate the meaning of the term “certified-EHR,” the $17 billion allocated for EHR adoption and use will largely be wasted.

The solution is to keep EHR certification rules simple to encourage an open market model. An open market will foster a competitive environment, leading to the emergence of user-friendly EHR software that is simple, helpful, efficient, and inexpensive – software that will improve both patient care and the day-to-day lives of our clinicians.

I appreciate your work and the work of the HIT Policy Committee members in crafting our new national health care IT plan.

Sincerely yours,

Richard Weinhaus, M.D.

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  1. we, supposed, was designed to attract the neighbouring blacks.

    Not only does a digger realize that it’s very possible he may locate a great deal of gold with very little trouble, but, worse still, he knows he or she work very, very hard without getting any gold at all. Finding the Venus reef abandoned he went for the Four Mile, two miles distant, and discovered about fourteen Chinamen camped there.

  2. I agree with much of what has been said about EMR’s here. i too am very frustrated with my experience with a popular EMR that has forged links with Dell and WalMart. It is a counterintuitive process and makes us clerks instead of thinkers. From time spent on accessing previously scanned data to typing information in, the time committment and data entry is incredibly wasteful. It is a sheer waste of our talent to be spending time on EMR’s to ensure that the clinical info in HPI matches the ROS and that one has to manually enter this information in. There should be a seamless flow of information from one location of the EMR to another. For example if a new drug is prescribed it should automatically populate the medication list and if it was prescribed for 10 days then it should automatically depopulate the medication list assuming it was taken. If a surgery was already billed it should populate the surgical history. I see fewer patients with longer wait times than ever before and there is always concern that some element of the note is incorrect. Instead of assisting us with decision making and simplifying the process, it has become more cumbersome and has transformed us into clerks. I feel that all the time that I spend on insurance filing, precertification, drug authorization, predetermination letters and EMR problems(system failure, wireless failure, connectivity issues, inability to access already scanned documents(on certain days), etc etc has moved me away from a thinking physician to a intelligent medical clerk that must follow the dictates of templates and algorithms. It has certainly taken time away from my patients and reduced valuable interaction with them. The amount of data streaming thru with EMRs is a significant burden for primary physicians and for all physicians who are constrained by time. On the other hand my staff’s experience has been generally positive as we have gone paperless. They eem to have more time and I less. I could not agree more that it requires more advanced planning and a thoughtful approach with more physician friendly data capture and data sharing.
    While the EMR is a more recent issue, our reimbursement is flawed so much worse than the EHR issue. Perhpas one day we can address the significant inequities that exist in the somewhat arbitrary RVU assignments and payments. Furthermore, how can it be that the same procedure that paid us $2000 in 1988 pays us $550 now, even though it takes just marginally less time, equal or perhaps greater skill and generally better outcome as newer technologies get implemented. It is a sheer mess.

  3. “It sounds as if AMDIS is describing a high risk of system failure. Could some of the problem be due to poor EHR design?”
    Um, well yes. Good system design doesn’t allow the user to make mistakes. Mediocre system design doesn’t prevent user mistakes. Poor system design encourages mistakes.
    We’ve already experienced multiple episodes of system failure, fortunately none leading to long term bad consequences so far. Our management intended to do the right thing by adopting an EMR (to replace the paperless system we were already using), but we got burned to the tune of $2M.

  4. From Rick Weinhaus to Scot Silverstein,
    Scot, thanks for the U.S. Air Force Guidelines (from the 1980s) for designing user interfaces. They still seem completely relevant. I was particularly intrigued by description of system failure: “Probably no single user interface design flaw, in itself, will cause system failure. But there is a limit to how well users can adapt to a poorly designed interface.”
    In regard to system failure, I was struck that AMDIS (see my reply above to Sue Reber, CCHIT) also recommended deferring CPOE (for hospitals) to 2013 or beyond.
    The letter states: “Even in the hands of our most experienced members working in organizations with EHR systems that are already up and running [presumably mostly CCHIT-certified systems], successfully implementing robust CPOE functionality is generally a challenging, multi-year undertaking that requires careful planning and execution.” AMDIS then goes on to recommend that CPOE be deferred because “it requires more advanced planning, building, testing, training, experience, data capture, data sharing and decision support than many practices and hospitals can successfully achieve in the next 2-3 years.”
    It sounds as if AMDIS is describing a high risk of system failure. Could some of the problem be due to poor EHR design?

  5. Rick Weinhaus replies to Sue Reber, CCHIT
    Sue Reber wrote: “You and other commenters may not be aware of CCHIT’s most recent announcement about including new certification programs that focus on the minimum federal requirements (ARRA/HITECH) for both modular EHRs and those developed on site.”
    Sue, thank you so much for responding as a representative of CCHIT. I welcome the opportunity to exchange ideas. I am aware of the new EHR-M and EHR-S certification programs. My concern is what will be the real life implications of having a three-tiered system.
    Let me give you an example. Just a few days ago, after the CCHIT announcement of the new certification programs, the Association of Medical Directors of Information Systems (AMDIS) wrote an open letter to Dr. Blumenthal and the HIT Policy Committee commenting on meaningful use. (http://www.meaningfuluse.org/Portals/0/AMDIS%20Response.pdf)
    In that letter, AMDIS made the recommendation to “use only EHR solutions that are considered ‘safe and effective’ by a trusted authority,” and later recommended that physicians and hospitals become regular and appropriate users of core functionalities in EHR systems certified under the 2008 CCHIT criteria.
    The AMDIS recommendations would seem to imply that CCHIT considers EHRs certified under 2008 criteria to be safe and effective. Is AMDIS suggesting that EHR-S systems, for instance, may not be safe and effective?
    What is CCHIT’s stance on these recommendations? Is CCHIT saying that EHR-C systems are safe and effective but that EHR-S systems may not be?
    Suppose a hospital installs an EHR-C system using ARRA/HITECH incentives and then requires all affiliated office-based physicians who want to admit patients to the hospital to use the same system (or another EHR-C system). Wouldn’t that scenario make EHR-S certification moot?
    It is because of these kinds of concerns that I favor standards focusing on data, data transmission, interoperability, and privacy, but not mandating the details of EHR software design.

  6. Rick Weinhaus replies to J Bean:
    J Bean wrote: “The product that I use now . . . doesn’t even meet the standards of the early 1990s . . . It’s not clear to me why there needs to be money invested in academic study of the [usability] problem.”
    J Bean, I find it useful to think about EHR human factor issues as high-level (user mental model – overview of how a patient’s health changes over time), mid-level (large scale screen design and UI idioms) and detail-level (number of clicks required, etc). The most usable software designs are those where human factors have been an integral part of the design process and operate at the high-level. Once a product has been fully developed, it’s very difficult to build in high-level usability after the fact. On the other hand, at the detail-level, and with much more effort at the mid-level, usability testing and evaluation can sometimes greatly improve a program. I’m in favor of doing whatever can be done to improve the usability of EHR software. That being said, I agree with you that there are probably certain EHR designs which can be thought of as system failures (see my reply to Scot Silverstein below).

  7. J Bean wrote:
    “15 years ago I was writing large scale training software for the military.”
    Here is mid 1980’s wisdom written for the U.S. Air Force on user interfaces. (Two decades later, healthcare IT design seems to be ruled by Mr. Magoo):
    GUIDELINES FOR DESIGNING USER INTERFACE SOFTWARE
    ESD-TR-86-278
    August 1986
    http://hcibib.org/sam/
    SIGNIFICANCE OF THE USER INTERFACE
    The design of user interface software is not only expensive and time-consuming, but it is also critical for effective system performance. To be sure, users can sometimes compensate for poor design with extra effort. Probably no single user interface design flaw, in itself, will cause system failure. But there is a limit to how well users can adapt to a poorly designed interface. As one deficiency is added to another, the cumulative negative effects may eventually result in system failure, poor performance, and/or user complaints.
    Outright system failure can be seen in systems that are underused, where use is optional, or are abandoned entirely. There may be retention of (or reversion to) manual data handling procedures, with little use of automated capabilities. When a system fails in this way, the result is disrupted operation, wasted time, effort and money, and failure to achieve the potential benefits of automated information handling.
    In a constrained environment, such as that of many military and commercial information systems, users may have little choice but to make do with whatever interface design is provided. There the symptoms of poor user interface design may appear in degraded performance. Frequent and/or serious errors in data handling may result from confusing user interface design . Tedious user procedures may slow data processing, resulting in longer queues at the checkout counter, the teller’s window, the visa office, the truck dock, [the hospital floor or doctor’s office – SS] or any other workplace where the potential benefits of computer support are outweighed by an unintended increase in human effort.
    In situations where degradation in system performance is not so easily measured, symptoms of poor user interface design may appear as user complaints. The system may be described as hard to learn, or clumsy, tiring and slow to use [often heard in medicine, but too often blamed on “physician resistance” – SS] The users’ view of a system is conditioned chiefly by experience with its interface. If the user interface is unsatisfactory, the users’ view of the system will be negative regardless of any niceties of internal computer processing.
    A convincing demonstration of design improvement has been reported by Keister and Gallaway (1983). Those authors describe a data entry application in which relatively simple improvements to user interface software — including selection and formatting of displayed data, consistency in wording and procedures, on-line user guidance, explicit error messages, re-entry rather than overtyping for data change, elimination of abbreviations, etc. — resulted in significantly improved system performance. Data entry was accomplished 25 percent faster, and with 25 percent fewer errors.
    This was over 20 years ago.

  8. Dr. Weinhaus:
    You and other commenters may not be aware of CCHIT’s most recent announcement about including new certification programs that focus on the minimum federal requirements (ARRA/HITECH) for both modular EHRs and those developed on site.
    You may read about that here: http://cchit.org
    Sue Reber, CCHIT

  9. HIT Usability:
    15 years ago I was writing large scale training software for the military. We already understood a lot about the human factors of software back in that primitive area. The product that I use now (rhymes with GextNen) doesn’t even meet the standards of the early 1990s. It’s not clear to me why there needs to be money invested in academic study of the problem. When you are wrestling with a product whose GUI is inconsistent from screen to screen much less fails to operate with the standard user prompts that Microsoft uses you are starting from a very low level indeed.
    I’m currently on vacation. This means that I have to use the EMR remotely for approximately 2 hours per day — because there IS NO WAY TO REDIRECT my tasks to another physician, even if they weren’t having trouble keeping their head above water with their own workload. A design that assumes that every physician works 365 days per year might seem just a tad deficient, even without an academic study, don’t you think?
    Add the speed and reliablility issues to a product that does little more than serve as an awkward word processing tool and you can understand reluctant adoption. Without an academic study.

  10. Reply from Rick Weinhaus to HIT Usability
    HIT Usability wrote: The industry needs to include folks who are experts at human factors and behavioral sciences (along with the clinicians and IT folks) to study user performance and UI design both in the lab and in the field….
    Hit Usability: I’m in complete agreement. As I commented to Sarah Greene, it is puzzling to me that what we have learned from cognitive and human factors research has played such a small role in EHR design. In my opinion, barely usable EHR software (not cost, insufficient training, fear of change or obstinacy) is weakest link in the HITECH initiative. As you know, the field of medicine remains far behind most other fields in terms of having usable software applications. The CCHIT model is the antithesis of good software design and has contributed to this situation. I fear that all the hard work being done now on ‘meaningful use’ will be moot if most EHR software remains as unusable as it is now. Hope your workshops go well. Let me know if you will be in the Boston area.

  11. Dear Rick, In response to your last comment…
    “HIT Usability: Thanks for you post and I agree with your suggestions, including that we should promote EHR innovation through user research…”
    — We’re on the same page and I couldn’t agree more. We are currently investigating and will be applying for funds (HITECH or other discretionary funds from ONCHIT) to study HIT usability with an academic medical center/center of excellence. The industry needs to include folks who are experts at human factors and behavioral sciences (along with the clinicians and IT folks) to study user performance and UI design both in the lab and in the field…. in the natural and mostly chaotic world of a health care professional trying to care for their patients. There are things that we can do now (that will make a big impact) and then longer term, more complex changes for the future. We have neglected this field in designing and building HIT solutions but it’s not too late to engage them now. There are experts out there who do this on a daily basis including our firm, User Centric. We will be hosting a one-day workshop at select cities around the country focused on HIT usability and are hoping to educate folks on what usability is and is not and provide some education and direction on how to measure and improve for EHRs and HIT in general. We anticipate very high turnout!

  12. Rick Weinhaus writes: “Scot, I have read your writings on usability and HIT failures with great interest, and it is clear that you have devoted much of your professional life to these issues. I have been particularly struck by your personal examples of how health care IT failures have caused harm to patients and clinicians. I would encourage readers to visit the links that you posted.”
    Thanks, Rick.
    However, still have not received any answers from anyone to my questions, the most important one being this. To repeat myself:
    For about ten years now, a google or other search engine query on “healthcare IT failure” or similar brings back my web site “Common Examples of Healthcare IT Failure” at http://www.ischool.drexel.edu/faculty/ssilverstein/medinfo.htm as very highly ranked – with little else relevant returned. I’d made many observations about health IT difficulties after a period as a CMIO a decade ago. The site has had many thousands of hits from all over the world, yearly, for a decade now. There are multiple links to other materials related to HIT difficulties as well.
    Question: Why is this site nearly unique after a decade?
    (I have my own theories, but I want to see what others think).
    Finally, I believe there cannot be a “culture of safety” from an organization with cavalier attitudes about safety proponents, i.e.,
    “Before ARRA, most surveys concluded that cost was the No. 1 barrier to EHR adoption. But as soon as it appeared that the cost barrier might finally be overcome, individuals with a deeper-seated “anti-EHR” bent emerged. Their numbers are small, but their shocking claims — that EHRs kill people, that massive privacy violations are taking place, that shady conspiracies are operating — make stimulating copy for the media. Those experienced with EHRs might laugh these stories off , but risk-averse newcomers to health IT, both health care providers and policymakers, are easily affected by fear mongering.”
    This passage shows a cavalier attitude towards HIT safety, and is the antithesis of a safety culture (mocking those who study and write on HIT safety issues) that would be entirely unacceptable if not indictable in other industries in which I worked (e.g., transit, pharma).
    — SS

  13. I read recently that before establishing a definition of “meaningful use” of the HIT products currently available, the vendors should be required to sell meaningfully useful technology.

  14. From Rick Weinhaus to everyone,
    Thanks for your comments and suggestions.
    What I am most struck by is that all of you clearly have first-hand experience with barely usable EHR software applications based on the CCHIT model, and you all agree that the CCHIT model is flawed to the point that it could sink the entire HITECH initiative.
    I want to respond to everyone’s thoughtful comments in turn.
    Wendell Murray asked “What product did you buy.”
    Wendell, I will be happy to email you the name of the EHR application I am using.
    To name one or more EHRs here might suggest that the usability problems are specific to those programs. My main point is that EHR usability issues are widespread and structural due to the flawed CCHIT model. Even good EHR software applications could be much better if they weren’t constrained by the CCHIT certification requirements.
    While I have not yet had the opportunity to spend much time at the PatientOS website or learn about the application, this is something I definitely want to do. I like the FOSS concept very much. Greg Caulton and I have exchanged posts on the EMRupdate.com website and we share the same philosophy about the need for usable software. In fact, Greg was hoping to create a working prototype of the TimeBar when he could find time to do it.
    Sarah Greene wrote: “It’s curious to me that human-computer interaction does not seem to have much traction in the EHR world.”
    Sarah, I have been puzzled by this as well. I have spent a lot of time reading up on human-computer interaction and I can find very little specifically related to EHR applications. One notable exception is the work being done at the Human-Computer Interaction Lab at the University of Maryland (www.cs.umd.edu/hcil/). Also, Microsoft has done some very good work with their Healthcare Common User Interface (http://www.mscui.net/DesignGuide/DesignGuide.aspx).
    HL7 Guy, Margalit and Wendell:
    I agree with all of you that the $20 billion or so in HITECH incentives will be largely wasted if used to implement EHR adoption nationally based on the CCHIT model. Margalit, I think the point you are making is that there are already very real differences in how usable different EHR applications are. I agree with you that the large, established vendors who have been around since the nineties tend to have the most unusable application. In support of this argument, see the 2008 American Academy of Family Physicians (AAFP) survey, where Centricity, TouchWorks (Allscripts), Cerner, Misys, and Nextgen rank dead last for usability.
    (http://www.aafp.org/fpm/20080200/25user.html)
    Margalit, I have not yet had the opportunity to see your company’s (genesysMD.com) EHR application first hand. From what you have written about it at EMRupdate.com, it seems extremely well thought out and crafted.
    To get a sense of the real cost of CCHIT certification, above the actual $30,000 fee, could you estimate how much time and resources GenesysMD has had to put into this effort?
    HIT Usability:
    Thanks for you post and I agree with your suggestions, including that we should promote EHR innovation through user research. I would also suggest that some of the HITECH incentive go toward research and development. I think that it is important to demystify EHR software applications and make the issues known not just to clinicians and HIT professionals, but to the larger community of computer professionals and students. For instance, suppose each university computer department in the country were given grant money to have their faculty and students work on innovative, usable EHR solutions. There could be competitions for the best designs for specific problems, etc.
    S Silverstein:
    Scot, I have read your writings on usability and HIT failures with great interest, and it is clear that you have devoted much of your professional life to these issues. I have been particularly struck by your personal examples of how health care IT failures have caused harm to patients and clinicians. I would encourage readers to visit the links that you posted.
    J Bean:
    Thanks. It sounds like we have had very similar experiences. The new national HIT Policy Committee needs to hear from clinicians like us. The Policy Committee needs to know that to know that the low adoption rates and high de-installation rates for EHR applications are not primarily due to cost, obstinacy, fear of change, or lack of training on the part of physicians. The goals of the HITECH initiative to improve health care, lower costs, and reduce errors will not be met using the CCHIT-certification model. Rather, we need an open market model where innovative, usable EHR applications are permitted to emerge.
    David and Margalit:
    Agreed. We should “certify” on safety, security, and standards use, period.
    Candida:
    Thanks, your points are well taken.

  15. Fascinating thread of thoughts. Let’s face it. The HIT and CPOE devices out there are an ergonomic failures and that alone renders them unsafe and not efficacious. But that is not the only defect harbored in these CCHIT “cerified” devices that cuases injury and death to patients. There are many that are worse and they are covered up. The magnitude of patient injury and endagerment is hidden.
    The fact is that these are medical devices and as such, none have been assessed for safety and efficacy. CCHIT leadership, when asked about what it does if they get a report that a “cerified” device malfunctions in the after market and results in death, stated that they do not consider after market surveillance in their domain.
    One can take this a step further. How is it that medical devices are being sold without FDA approval?
    And another step, I query, is this not an experimental device and are patients whose care is under its control not serving as unconsented subjects to benefit the HIT device vendors?
    And are the doctors who are forced to use these ill-conceived unusable devices also not guinea pigs by providing free advice to the device makers while creatively coming up with work arounds so that they can keep their patients alive despite the device?
    Please someone, send this to Blumenthal and your Senators and Reps inside the beltway.

  16. Margalit: I think you’ve hit on it precisely. My hope is that this idea will surface during the certification day hearings for the HIT Policy Committee July 14th in DC, and that perhaps the Committee members themselves might suggest this path and investigate its practicality.
    For one thing, keeping the certification process simple and focused on safety, security, and standards use (S-3) will minimize the cost and complexity for the government, while allowing several entities to be certifiers. That makes sure there is no monopolistic control by a single contractor for certification, and also assures vendors their products can get swift certification, without lines or long waits. It should also keep the costs of certification to the vendors very low. We might see hundreds or even thousands of new applications enter this market and vie for purchaser’s loyalty with lower prices, better service, etc.
    The evaluation of products and services in the EHR technology space could be jump-started by an AHRQ grant to their own NRC, or to one or more outside organizations, like Consumer Reports, or both. With enough interest in the market, and with enough new entrants into the market, it may be possible to eventually fund the evaluation process by charging small subscription fees to the potential users, as Consumers Reports functions now.
    Kind regards, DCK

  17. That’s a fantastic idea David. Maybe Dr. Blumenthal should come up with two separate “certification” suggestions similar to the auto industry.
    1) A minimal set of standard security and safety items. Nothing too fancy and complicated. Something like car emissions and inspection that products have to pass every year in order to “stay on the road”.
    Once the criteria are set, the inspection and certification body should be distributed, just like the inspection centers for cars, and multiple private bodies should be able to apply for the status of “Certification Center”.
    2) This should be in the form of funding a Consumer Reports like entity, that is completely ant totally unbiased, for evaluating EMRs and other health care applications.
    The Healthcare Consumer Reports should have very strict regulations regarding who it can receive funding from. Maybe the folks at the real Consumer Reports would like to take this one on. I would be inclined to trust them more than anything else that comes to my mind right now.

  18. Rick and others: I’m very glad to see the maturing of the conversation about EHRs and their “certification.” What we need is a system for evaluation, not just certification, of this technology. Ross Koppel has written about this idea, the benefits of which are pretty clear. User experience is very important, and does not belong in a “certification” program. My suggestion is that we “certify” on safety, security, and standards use, and then evaluate on price, ease of use, quality improvement enhancing capability, and other aspects of performance and value. This is what Rick and many other doctors who have experience with EHR technology are now telling us, loud and clear. Regards, DCK

  19. I agree 100% with Dr. Weinhaus. I was a software engineer for a decade before going to medical school. I type fluently and use computers with no concern, but I am frustrated beyond belief with the EMR that I’ve used for the last 10 months. It does absolutely nothing useful for me.

  20. HL7 Guy,
    A few years ago, we all wrote with pens on paper. Now most of us type everything. Written assignments/articles/scientific papers/letters are practically non existent. That didn’t seem to hinder our natural workflows too much.
    Physicians that do not use EMR technology currently, are imputing information into paper systems either by writing or by speaking. I guess that is their “natural workflow”. Some brave ones are entering information by typing into word processors, which are constantly held up as the epitome of simplicity and ease of use as compared to clunky EMRs. Their natural workflow seems to be just fine too. Others use mice and stylus and dictation, or a combination, and their natural workflow seems to have adjusted to the newer gadgets.
    I think the problem is the amount of data that needs to be entered and less so the actual input device. Somehow physicians feel compelled to enter more data when they use an EMR compared to when they scribble on paper and it looks like now it will be required to amass all sorts of discrete data.
    All that said, most EMRs that I have seen (maybe 20-30 or so) leave much to be desired in terms of usability. I don’t believe that this is due to lack of artificial intelligence. Most likely it is due to the fact that these software products are reaching their natural end of life. Some were designed well over a decade ago and they were state of the art back then. Some are still pretty decent, but an overhaul is probably in order.
    The problem is that in order to survive with minimal investment, these vendors are trying to focus the entire industry on function points – hundreds of spaghetti functions points that were accumulated over a decade of fixes and enhancements. Elegance and usability that you see in most new software applications in “non-certifiable” markets are being pushed aside.
    Maybe one day artificial intelligence and sophisticated algorithms and holograms are going to replace the stylus/mouse/keyboard tools, if we don’t burn this planet down first, but this is not an option for Dr. Blumenthal right now. I would happily settle for the freedom to explore new technologies without having to keep up with the dinosaurs as a prerequisite for sheer existence.

  21. What is being described by Dr. Weinhaus is a mission hostile user experience. See http://www.interaction-design.org/encyclopedia/user_experience_or_ux.html
    Perhaps part of the problem is that in the late 1970’s and 1980’s the HIT vendor community took the (at the time) half-based ideas of the medical informatics pioneers who first explored the uses of computers in medicine and ran with them. For example, in 1992 I had the distinct displeasure of helping implement a CPOE system by TDS/Alltel whose user experience made me long for my 1978 TRS-80 Model 1.
    Firmly planted in the 1980’s with regard to biomedical HCI the industry largely remains. See http://tinyurl.com/b28s74
    Reunification of the HIT industry with modern medical informatcs research is near impossible, as people in the HIT vendor community are largely contemptuous of those who have built on the traditions of the pioneers.
    What I really want to know is this, however:
    For about ten years now, a google or other search engine query on “healthcare IT failure” or similar brings back my web site “Common Examples of Healthcare IT Failure” at http://www.ischool.drexel.edu/faculty/ssilverstein/medinfo.htm as very highly ranked – with little else relevant returned. I’d made many observations about health IT difficulties after a period as a CMIO a decade ago. The site has had many thousands of hits from all over the world, yearly, for a decade now. There are multiple links to other materials related to HIT difficulties as well.
    My questions are:
    1. Why is this site nearly unique after a decade?
    and
    2. Do HIT industry leaders actually read the biomedical literature regarding the undesired adverse effects of the products they sell?
    While CCHIT chair Mark Leavitt calls the writers of such literature “fear mongers” who should be laughed at (see http://hcrenewal.blogspot.com/2009/06/mark-leavitt-head-of-cchit-behind-times.html ), I don’t think the realities are a laughing matter.

  22. Margalit Gur-Arie,
    If there is a keyboard and a mouse to feed the data then I stand firm on my statement, even with the newest applications from the recent past years. I base my numbers by having worked with a myriad of applications during the past 23 years, from dumb terminals up to touch screens with voice recognition.
    I am not saying that the application is poorly designed according to standard industry practices. The application may be perfect but the means to introduce the information is archaic for what is really needed.
    Computer technology as is has proven to be of little value to clinicians. That’s why there is an untapped market of over 80%. They get frustrated with how technology disrupts their natural workflow and how obtrusive it is to their patient encounters.
    Emerging technologies based on Artificial Intelligence and sophisticated algorithms will open the gates to newer input means.
    The problem is the keyboard not the application. But in many cases new applications as well as older antiques are the problem too.
    Thanks

  23. I completely agree with you Dr. Weinhaus. If doctors can’t use technology, it doesn’t work! A study just came out by Nuance that showed 90% of physicians cite usability as critical to EHR adoption. http://www.nuance.com/healthcare/ehr-meaningful-use-study/
    We should strive to improve EHR usability through solid research-based user testing through:
    – Guidelines and Design Patterns
    Guidance to the field that promotes high earnability, positive transfer of training, consistency of approach, without stifling creativity or competitive advantage.
    Design patterns based upon best practices.
    Visualizations.
    Efficient, effective methods of representing data that return high value to users.
    – Measurements
    Creation of reliable and valid techniques for measuring user experience and reporting on real user performance outcomes in a meaningful way.
    We should promote EHR innovation through user research on these and other healthcare IT solutions. Adoption is not going to drastically increase if doctors are not able to use these systems but there are many things (some simple, some more complex) that we can do to help right now and then through iterative testing and improving. We must include the right people and backgrounds who have been studying and improving human-computer interaction for years.

  24. I agree with practically every word in Dr. Weinhaus’ letter.
    I also agree with Wendell. If I had $20 billion, I would rather fix more urgent problems in this country.
    However, HL7 Guy, when you make a statement like “For an hour of clinician and patient interaction there is approximately an hour of data input as most EMR applications are currently built.”, how many of the 200+ EMRs on the market have you tested your assertion on? Should be more than 100 in order to make the statement accurate.
    Have you tested that many, or are you relying on the “usual suspects” sample of a dozen or so EMRs that have been around since the early ninties, or even earlier?

  25. While were in the fundamental issues of systems and useability design, let’s not forget another pesky problem for effective EHR. As with any record keeping/exchange system the problem is how to manage identity. Whose records are whose? How to uniquely identify someone and their records becomes central to the function of the system, platform or interchange. It all comes back to identity management and security. Who formulates/creates, who manages/controls/assigns the identities, who regulates and enforces? Does health care reform have the potential to address the parallel problem of credit reporting? Does it raise the same big brother bogeyman of national IDs?

  26. There are real and tangible reasons why Information Technology as it exists is of very little help to many clinicians.
    Gathering the information to feed into the systems is obtrusive and disruptive to the clinicians workflow.
    For an hour of clinician and patient interaction there is approximately an hour of data input as most EMR applications are currently built. This is extremely inefficient.
    Clinicians aren’t secretaries or clerks that can be typing away all day. They have to cure and save the lives of their patients.
    Frustrations imposed by improperly built software have created an apathetic attitude from most clinicians towards technology.
    Until technologists understand this and start building solutions based on use cases and that fit seamlessly into the clinicians workflows, adoptions will be scarce and the failure rate will be high.
    Thanks

  27. Provocative and useful post, Dr. Weinhaus. It’s curious to me that human-computer interaction does not seem to have much traction in the EHR world, and yet in the consumer-centered Personal Health Record community, it is a guiding principle. While some might wonder if this suggests that doctors are super-human compared with patients (grin), it strikes me that the EHR developers of the world could take their cues from patient-focused efforts such as Project Health Design (www.projecthealthdesign.org)

  28. What product did you buy? E-mail me if you do not want to publicly post it.
    Check out PatientOS http://patientos.org an excellent FOSS EMR/PM (practice management) product developed by Greg Caulton that he and others are still working on, but which is implementable as is.
    The $20 billion in allocated ARRA funds should go to providing medical services to the poor. If some of the funds are used to implement HIT they should be used only for training and education of patients and providers alike so that they know how to use computer tools such as PHRs and EMRs.

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