Physicians

(Over)Simplifying EHR Usability

Dr. P patted the middle aged patient on the back, helped him off the elevated exam table and guided him to the chair by the sink. He picked up the chart and using the exam table as his desk he flipped through the chart, pulling out several pieces of paper, spreading them to his right, while making small talk with his patient. He reached into his pocket and pulled out a battered silver recorder and without any warning started dictating: “Mr. H is a 60 year old mildly obese gentleman presenting with…..“.

He had a pen now in his right hand, and as he was talking into his recorder, shuffling the various papers in front of him, he was also writing orders and prescriptions as fast as he was dictating. “….follow up in two weeks” was the last thing he said. He didn’t write that one down, but turned around, handed the patient a bunch of scripts, told him to stop by the front desk and make an appointment two weeks out and stop by the lab on the fourth floor to pick up a container for the urine test. Two minutes, tops, including the small talk. It was my turn now and I was sweating bullets because I knew exactly what he is about to say. “Can I do this in the EMR?”

EHR usability has finally arrived to Washington as the guest of honor at the most recent ONC HIT Policy Committee hearing. ONC seems to be considering the regulation and certification of EHR usability. NIST has created a testing procedure and just like its Meaningful Use testing procedures, it is superficial and doesn’t really test anything of any consequence. Those who represented “providers” and patients argued for the need to improve usability and those who represented academia and grant funded research argued for more funded research. Predictably, usability experts, argued for hiring more usability experts. Large vendors eloquently stated their objections to government mandating what EHRs should look like and small vendors argued that the more mandates, the better, since this will automatically remove the built-in competitive advantage of those with larger budgets and larger usability departments. As is customary, EHRs were compared to ATM machines, cars, iPhones, Google and a variety of “other industries” that are all so much more advanced than health care when it comes to usability.

When usability, or lack thereof, is discussed, most actual users of EHRs (oddly, there was only one of those at the ONC hearing) think about too many clicks, too many screen changes, convoluted workflows, stilted terminology, finding needles in haystacks, slow and freezing software, crashed servers, disappearing information, mind numbing alerts and lack of functionality. But wait, there is more… There should be out-of-the-box interoperability, ability to customize everything, thousands of templates, no bugs, no need for training, no need to document all that crazy billing stuff, and it wouldn’t hurt if it looked pretty and colorful (as opposed to “dull”), and it should work on the iPhone, iPad, Blackberry, Android, Mac and Windows 98 too.

There are two questions facing all involved: How to measure usability, and who should define and measure usability. The ONC committee is presumably exploring whether government should be the answer to both questions. Before you cheerfully agree that government should indeed regulate EHRs through an FDA approval process, let’s take a minute and explore what it is that we want government to regulate. No doubt, we want government to ensure safety of patients. Since EHRs are part of the clinical process, the FDA has, in my opinion, a clear and definitive role in making sure that EHRs do not endanger people’s lives. Usability, however, is a much larger aspect of a product than safety. To use the completely inappropriate analogy to automobiles (more on that later), it is pretty obvious that government should mandate that cars come with airbags and seatbelts, but it is less clear that government should mandate that all vehicles come with heated seats or automatic transmission, even if manual transmission and freezing bottoms may be tied to some types of accidents, for particular types of users, in particular circumstances, at particular times of day. And here is a trickier question: should the government fund and engage in the design of a preferred seatbelt, and then require that all automobile manufacturers use the exact same design?

Back to the more general question of usability and how it should be measured. ONC is funding projects and the government is paying for contracted work to provide an answer to this question. The initial outcomes as presented at this hearing consist of a rather strange standard form for assessing effectiveness (success/failure), efficiency (time to completion) and satisfaction (subjective) for several use cases based on narrow Meaningful Use criteria as defined by NIST testing procedures for certifying EHRs for Meaningful Use incentives. For example, an evaluator would be asked to prescribe a statin for a patient, or record vital signs, or execute a similarly granular sub-step of real life clinical scenarios. I don’t think I need to belabor why this exceedingly simplistic approach provides no indication for evaluating usability of the EHR. However, as one participant stated during the hearing, it seems that it is better to measure something than nothing. If you are reading this and you are a physician, this way of measuring things out of context, just because we can, would be akin to measuring the percent of patients sitting in your waiting room at a random date and time with a blood pressure under 130/70, and deciding that you are a good doctor if they all do, or a bad one if they don’t, whether you are a pediatrician, a geriatrician, or if you practice in a posh suburb, or tending mainly to indigent and homeless folks, or if it just so happens that this is the time when you do sports physicals for the local boys’ lacrosse team.

To continue on this path to oversimplification, there is a much circulated drawing in the circles of EHR usability experts (created by a former colleague of mine, Eric Burke), depicting three screens: the first shows an Apple screen with one word on it – “touch”, the second shows Google’s famous home page with nothing but a Search button, and the third is a cluttered data entry screen supposedly belonging to an EHR. This drawing is supposed to impress upon us how horrific EHR designs are by comparison to “other industries” and other software products we use in our daily lives. I’m not totally sure what the Apple screen is supposed to symbolize since touching a blank screen does nothing for me (sorry, Eric). I do understand the Google search screen and I agree that if you only want to do one thing, you should only have one button. When you want to do many things, many business and enterprise type things, it would be more meaningful to compare an EHR screen to say, SAP, or Siebel, or Epicor, or Photoshop, or any serious CAD application. The results of such comparison may surprise some usability experts, who seem to have all the answers. EHRs are not leisure applications for consumers and EHRs are not gaming platforms. To use the automobile example one last time, EHR is to iPhone and Facebook what a Ford F-150 is to a Little Tykes Cozy Coupe.

In conclusion, I would like to leave you with a screenshot of a widely used EHR. It indeed defies almost every single usability expert generated opinion on what good design should look like. However, if you look very carefully at the top-left of the screen, you will see that this is a screenshot from VistA, the VA EHR, designed and built by clinicians for clinicians. I have not met a single doctor who used VistA and did not really, really like it.

So let me ask again, who do you think should decide what a good and usable EHR should look like, a Government usability expert or Dr. P?

Margalit Gur-Arie was COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization. She shares her thoughts about HIT topics and issues at her blog, On Healthcare Technology.

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UsabilityPeopleRileyWendell MurrayJoleanMichael29 Recent comment authors
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UsabilityPeople
Member

Many EHRs really do suck, as ZDoggMD described in his very popular parody video ‘EHR state of Mind’. But without some nudge towards an improved user experience many of the “less than optimal” EHRs will only get worse as they grow and Engineering-centric developers add more and more features on top of a poorly designed information architecture. Vehicles are not allowed to be sold in the USA unless they have meet strict safety standards, why isn’t this the same for EHRs? Don’t like 30 clicks to order Ambien? How about 50! Usability in healthcare is critical to patient safety, but… Read more »

Riley
Guest

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tried the same product to stay fit and toned.
But it will help make you more susceptible to cancer.
The odds of a good candidate for weight loss? You want your weight loss to be coupled with
no sugar. The scientific approach of this e-book aiding to lose weight without Dieting Vegetables.

Wendell Murray
Guest

Margarit is among the best on topic. Keep in mind she is not even a native speaker of English. I usually agree with her, but she is somewhat off in this posting.

Jolean
Guest

I just wanted to thank you for the article, it was certainly thought provoking. I think we are all in a very interesting time where UX, the lack thereof, and how to measure it are mere forerunners in the landslide of questions coming about EHRs, how to use them and how to use them “meaningfully”. As technology evolves to address these concerns, new concerns will continue to crop up. The key is keeping your health care IT professionals and vendors as educated as possible and providing tremendous room for R&D, without which the EHR will never reach it’s full potential.… Read more »

QA
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QA

“QA, you are mixing up concepts here. You are again quoting examples of things made in factories, and you are again talking about safety. I am sure you understand that usability is a tad larger subject than safety.” Hmmm…last time I checked displays in nuclear power plants, aircraft gauges and flight monitoring displays, medical device software and many other systems regulated by the federal government weren’t made in factories…any more than say EHRs are “made in factories”. Unless you’re arguing that human factors engineering shouldn’t (or can’t?) be applied to software (or maybe just health IT software)? There are many… Read more »

Margalit Gur-Arie
Guest

The common denominator to your examples is that they are all tangible goods. There is a big difference between, say, a display in a cockpit or some other gauge and pure software, which is just bits and bytes. And as Dr. Levin explained above, the way EHR software is used is indeed different than anything else out there. By definition. User error is not always associated with safety issues, and safety issues are not always due to user error. Use centered design is most definitely not requiring users to become software engineers. However, they should define the metrics, i.e. what… Read more »

Michael29
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Michael29

There is a great need for innovation in healthcare especially in data collection side. It makes no sense that a physician who is a highly specialized professional should be doing data entry. Most of the information physicians enter is collected from the patient anyway. Why shouldn’t the patient enter this information. We saw this application and decided to not deal with entering mundane data again (http://123diagnosis.com) There will be no savings created in healthcare unless more technology is put in place. Things like self-directed lab analysis, increased over the counter medicine (or behind the counter/non presecription medicine) will lead to… Read more »

QA
Guest
QA

Margalit said: “it is mighty presumptuous to assume that any one Government can decide what is good technology and what is bad technology” So I guess we should throw out the human factors evaluation / certification programs at the Nuclear Regulatory Commission, the Federal Aviation Administration, the National Transportation Safety Board, the Food and Drug Administration, the Consumer Product Safety Commission, NASA and the military? Gary Levin said: “The end user ultimately determines usability, and frequently one cannot pre-determine that factor until the system is used. Setting a standard for usability will be a meaningless exercise in more governmental monetary… Read more »

Mark Spohr
Guest

If I may jump in here with a clarification from my point of view and what I stated in an earlier comment. I don’t think I or Margalit are arguing that the” user-centered design process is worthless”. I have had extensive experience designing software (and I believe Margalit also has similar experience) and I am a firm believer in the value of good software design in making systems easy to use and to help prevent errors. My point is that this is not something that can be codified in government regulations. I know good design when I see it but… Read more »

Margalit Gur-Arie
Guest

Couldn’t have said better….

Margalit Gur-Arie
Guest

QA, you are mixing up concepts here. You are again quoting examples of things made in factories, and you are again talking about safety. I am sure you understand that usability is a tad larger subject than safety. No one here is arguing against imposing patient safety regulations on EHRs and no one is debating the merits of human factors evaluations. However user-centered design is just that: user-centered. And the users are doctors, and yes, you should ask doctors to assess and design systems. You should ask them before you start the development process, continuously during the process and after… Read more »

David Tao
Guest

Margalit, thanks for a fine thought-provoking post. Many replies have occurred since I read it, and I haven’t had chance to read them all yet. I have just one quibble with your statement that “Large vendors eloquently stated their objections to government mandating what EHRs should look like and small vendors argued that the more mandates, the better, since this will automatically remove the built-in competitive advantage of those with larger budgets and larger usability departments.” That implies that the testimony for/against government mandates was split among EHR vendors, but the written testimony indicated that only the rep from CureMD… Read more »

Margalit Gur-Arie
Guest

David, I might have been unclear, and I should have stated the actual numbers of various representatives. I do not think that large means bad or good, or that small has any of those meanings either. I do however think that it is infinitely easier for large vendors to engage in quality usability research and implementation, than it is for a smaller vendor who may only have a handful of resources and a handful of dollars. Large vendors are much better positioned to do effective usability work, exactly because they have larger install bases and because usability done right is… Read more »

Gary Levin MD
Guest

QA, I am not certain from which you are coming with your comments about Margalit, whether you are from the health space or another IT space. From a physician perspective and from one who has used multiple EMRs, including VISTA, the DOD EMR and private EMRs, the healthcare space is vastly different than industrial or banking software applications. The most obvious difference are the variable tasks performed by each users. In a banking or industrial space the users are frequently assigned or use one particular feature of an application, assigned to their particular niche in the organization. Not so in… Read more »

pcp
Guest
pcp

QA writes: Dr. Lowry’s testimony, of course, stated the opposite: “Let me be clear: the usability evaluation program (EUP) is focused on helping developers of systems assess and demonstrate that their software is free from design-induced user-error and will not dictate particular user interface designs.” If that’s true, then NIST seems to be taking on some of the safety issues that the FDA should be handling, and not addressing usability issues, as Dr. P and I would define them, at all. Check out the recent posts on “Health Care Renewal” about the lack of usability of the CPOE system at… Read more »

cory
Guest
cory

One thing people must realize – there are the user aspects of EHRs and the actual medical implications of EHRs. Being able to retrieve X-rays or immunizations or transfer information is a different issue than what the computer means in terms of patient interface and medical decision-making.

There are far more people who can address the former than the latter.

http://www.guardian.co.uk/commentisfree/cifamerica/2011/apr/23/nhs-health

Margalit Gur-Arie
Guest

Thanks for the excellent link Cory. I would like to quote a couple of sentences from this reference: “Good technology is adopted. Bad technology isn’t – it’s always that way. All the government money and training in the world doesn’t change that. Spend it on patient care.” I would add for QA’s benefit, that it is mighty presumptuous to assume that any one Government can decide what is good technology and what is bad technology, as the NHS seems to be discovering as it goes along. And to use a common platitude from the general health care debate, in a… Read more »

QA
Guest
QA

Margalit is quickly becoming the nation’s single best source of mis-information on EHR usability. The CIF (Common Industry Format) that you poo-poo was actually developed by the IUSR working group of usability experts from purchasing and supplying companies, including companies such as IBM, Microsoft, Hewlett-Packard, Boeing, US West and Kodak.. It was based on collating best practices from the different companies, and aligning this with ISO 9241-11. It became an ANSI/ISO standard in 2006. The idea that it isn’t useful in the context of EHRs is ludicrous. Margalit speculates that EHR Evaluatiojn Protocol that NIST is developing will dictate user… Read more »

Margalit Gur-Arie
Guest

Mr/Ms QA, thank you for the dubious compliment. First and foremost, I would like to clarify that I am not opposed to usability testing and/or human factors analysis and/or UCD for EHRs or anything else. Quite the opposite. The only question here is who should do the actual work, and who should make the decisions. I believe in a quasi free market, it should be the sellers and the buyers. The CIF is a format for reporting usability tests results and the ISO standard you are quoting is a definition of “how” to measure and test, not so much “what”… Read more »

MD as HELL
Guest
MD as HELL

So hobbling the doctor is OK as long as the staff might have future benefits and the patient might have future benefits. You are OK with decreasing productivity by 150%. This will be useable how?

Margalit Gur-Arie
Guest

No, it’s not OK, unless the doctors chooses to “hobble” his/her performance for ancillary benefits and this is why folks need to be honest upfront. Now, the amount of hobbling is largely dependent on how a doctor documents on paper. If he is fast and efficient like the doc described here, he will be hobbled. If he is in the habit of writing extensive documentation for each visit, he may be less, or not at all, hobbled. Here is an interesting thought, though. I suspect that the hobbled party may be the patient. In successful EHR implementations, physicians are able… Read more »

Margalit Gur-Arie
Guest

I do agree with Leonard, and to QA’s point, I understand that usability is quickly becoming a science and rightfully so. Human Factors Engineering has been around for decades, and since my previous life was spent in the Aerospace industry, I know how valuable HFE can be. However, I have a hard time accepting that ideas and thought process developed for manufacturing of products is easily ported to enterprise software. Also from the NIST testimony: “In developing our guidance to measure the usability of EHR systems, we are adopting existing best practices, such as the FDA human factors evaluation process;… Read more »

Margalit Gur-Arie
Guest

First some house keeping. Not sure why, but the hyperlinks are not in the post, so here they are: ONC Hearing – http://healthit.hhs.gov/portal/server.pt?open=512&objID=1473&&PageID=17117&mode=2&in_hi_userid=11673&cached=true NIST Form – http://www.nist.gov/customcf/get_pdf.cfm?pub_id=907312 UI drawing – http://www.nist.gov/customcf/get_pdf.cfm?pub_id=907316 Eric Burke – http://stuffthathappens.com/blog/2008/03/page/3/ I do agree with Leonard, and to QA’s point, I understand that usability is quickly becoming a science and rightfully so. Human Factors Engineering has been around for decades, and since my previous life was spent in the Aerospace industry, I know how valuable HFE can be. However, I have a hard time accepting that ideas and thought process developed for manufacturing of products is… Read more »