I was absent-mindedly playing with my iPhone today and took special notice of a feature I have rarely used before. If you swipe all the way to the left on the home screen, you will get a search bar to search all of your iPhone. This includes contacts, iMessages, and apps. I’ve never needed to use this before—a testament to the iPhone’s ease of use. Just prior to this, I was working on some patient notes using my hospital’s electronic medical record (EMR). In contrast, each task I performed required a highly-regimented, multi-click process to accomplish.
Criticizing EMR interfaces is a well-loved pastime among clinicians. Here, however, I am going to take an oblique approach and reflect instead on what has made good interfaces (all outside of medicine, it turns out) recognized as such.
The Google Algorithm often gets credit for Google winning the Great Search Engine War. Indeed, there are whole teams dedicated to improving it. However, if you compare algorithms today, even 5 years ago, the differences in results have been only marginal. How does Google stay ahead? Speed. Google has done extensive research to determine what keeps users coming back and it is unequivocally speed of results. It has been much of the motivation for creating their own browser (Chrome) and operating system (Android). Speed means more searches and more searches means more money for Google.
With EMRs, wait times to store and retrieve data can be extremely long. Moreover, it frequently takes multiple clicks to get to the precise page you want, further compounding the problem. But how slow is slow? Research in web user behavior indicates that 47% of consumers expect a web page to load in 2 seconds or less and that 40% of people abandon a website that takes more than 3 seconds to load. It regularly takes over 3 seconds to retrieve an important piece of data from an EMR. That makes the experience constantly frustrating; I wish there was another EMR I could switch to. (As a fun aside, I often find myself logging into two computers side-by-side in the hospital to save precious seconds waiting for the computer to load.)
A highly-regimented click pattern to obtain results means that you have to be constantly aware of what you are going to click next. Compare that, for example, to the Facebook Newsfeed where the next step is always “Scroll Down.”
Fortunately, consumer web has discovered a better way for reaching your destination. Why not let people search everything in one place and guess at what they’re looking for? Examples include the iPhone search I opened this post with, the original Awesomebar on Firefox, and, of course, Google search (which lets you type in flight times or conversions like “lbs to kg” along with your usual searches). The main point is that you have one destination from which you can intelligently, semi-algorithmically branch off into any workflow you could need whether that is texting a friend or searching for the air speed velocity of an unladen swallow.
The trouble is that it is hard to do this “awesomebar” search well without knowing what the clinician is looking for. What do you mean when you start typing in “echo?” Which patient are you talking about with the first name “Rose?” In fact, this has been attempted before in healthcare in the form of Amalga, which was sadly mismanaged after being purchased by Microsoft from its founders. In principle this is very doable, vendors just need to listen to and understand their users. It’s been said before, but EMRs would do well to involve clinicians in the design.
This is often cited by users as the most frustrating part of the EMR experience and so I am not going to dwell on it. Cluttered interfaces and uncertain visual hierarchy both make it harder to use software. I hope it is clear from the above that even a nice visually-appealing interface can have problems if it doesn’t incorporate speed and search.
Of course, the ultimate problem is that EMRs are enterprise software, where the payers are not the users (clinicians) but rather the executives who are thinking about how this will improve the bottom line. I don’t see this changing anytime soon, moreover, as consolidation and physician employment (rather than self-employment as has historically been the case) becomes more popular. The popular EMRs do a good job of making sure hospitals get paid, but they do not do a good job optimizing for speed, search, and interface. If it is going to change, it will have to come from the small concierge practices that are emerging with novel clinical and financial workflows requiring custom solutions.