Tech

All I Want For Health IT Week Is An EHR Overhaul

Robert W WahIf I had to capture the main shortcoming of electronic health record (EHR) technology in one word, this would be it: Usability.

As we’re observing National Health IT Week through Friday, I can’t think of a better time to call for EHR systems that better serve physicians and our patients. That’s why the AMA just released a new framework for improving EHR usability.

As a chief medical officer for a health IT company and a former deputy national coordinator in the Office of the National Coordinator for Health Information Technology, I understand the complexities of what’s required to make EHRs first and foremost usable systems for the medical practice. When I say “all” I want for Health IT Week is an EHR overhaul, I realize that’s no simple request.

But it is a basic request. Usability should be the driving quality of all health IT. Unless health IT functions in a way that makes our practices more efficient and facilitates improvements in our patient care, it isn’t doing what it was intended to do.

As my colleague Steven J. Stack, MD, AMA president-elect, has said, most physicians are stuck with technology that interferes with their ability to provide first-rate medical care. And that’s reflected in physicians’ professional satisfaction.

In the AMA’s study with the RAND Corporation released last fall, we identified that the primary driver of physician dissatisfaction was EHR technology that put up barriers to delivering high-quality patient care.

As part of our Professional Satisfaction and Practice Sustainability initiative, we convened an external advisory committee of noted health IT experts and practicing physicians to develop priorities that should illuminate the path for improving the usability of EHR technology to benefit physicians and their patients.

Dr. Stack chaired this committee, which was responsible for developing the new framework (log in) we released this week. The framework outlines key challenges physicians face with EHRs and eight priorities that should be national priorities for improving the usability of this technology:

  • Enhance physicians’ ability to provide high-quality patient care
  • Support team-based care
  • Promote care coordination
  • Offer product modularity and configurability
  • Reduce cognitive workload
  • Promote data liquidity
  • Facilitate digital and mobile patient engagement
  • Expedite user input into product design and post-implementation feedback

The framework is particularly important in that it was developed by a combination of practicing physicians and noted experts, researchers and executives in the health IT field. So we were looking at how to improve EHR technology from a variety of perspectives, and the concepts offered are ones that can be executed.

To that end, we will be working with all stakeholders—physicians, vendors, federal and state policymakers, institutions, health care systems and researchers—to take these principles from ideas to realities. I look forward to witnessing the progress we’ll make by this time next year.

Robert W. Wah, MD is president of the American Medical Association

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Tommy G. ThompsonjordanLegacyflyerPaul SlobodianTalos Recent comment authors
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LeoHolmMD
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LeoHolmMD

“While there have been improvements in electronic health record technology and use…”

Have not noticed any of those. In fact, more burdensome than ever. EMRs are being adopted, but that is not the same as improving use. Many physicians are just finding ways to get around it. Scribes are an example. Even that doesn’t fix the problem with obfuscated data.

Tommy G. Thompson
Guest

As Secretary of Health and Human Services, I saw firsthand the big picture challenges that this post discusses – and those issues the commenters are raising. We attempted to kickstart an initiative, under the leadership of Dr. Brailer in 2004: http://archive.hhs.gov/news/press/2004pres/20040721a.html While there have been improvements in electronic health record technology and use, we can and must do so much more to ensure doctors have the information they need to provide effective and comprehensive care to their patients. Hopefully, the AMA’s efforts will help focus all of the relevant players in the health system to adopt seamless, effective electronic health… Read more »

jordan
Guest

Doctors dont want screens, they want good medicine. EMR’s are wait-a-bases (wB). Data just sits there and waits. What we want is actionable information, not more data sitting in a container with shitty UI and more clicks for billing and charting.

Dr. Ignacio Valdes (a medical doctor possessing a master’s degree in computer science with a stellar reputation in the health IT community) has frequently said, “For decades, doctors had no idea what they wanted, and software developers have given it to them.”

Legacyflyer
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Legacyflyer

The most amazing failure of the EHR is the lack of standardized format and readability of one EHR data in another.. Take your medical records from your docs office to the hospital – most likely can’t be read. Take your medical records from one hospital to another – most likely can’t be read – except with an expensive custom interface. Talk about stupidity/poor planning – this is epic! (Recently was forced to take EPIC EHR software training. Bad software!) And it is not like this is the first time this issue has come up. More than 10 years ago, Radiology… Read more »

@BobbyGvegas
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“The most amazing failure of the EHR is the lack of standardized format and readability of one EHR data in another”
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See my Blog.KHIT.org. Current post.

Paul Slobodian
Guest

I am amazed no one seems concerned with patient trust and confidence having personal medical information….often related to life style choices….entered into an EHR. Should I engage in personal behavior that might be medically relevant I don’t think I would tell my primary care doctor about it unless it were an emergency or unless he agreed to keep off line records. But perhaps my worry is just symptomatic of a paranoid delusion forming???

Talos
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Talos

Healthcare has seen an incremental creep on the demands for data for the last 2 decades as more and more data becomes digitalized. Now, in the last 10 years, doctors have moved from being medical providers to health data input specialists with outcome responsibilities, measured on any parameter which can be squeezed out of the data stream that somebody else deems special and “needed”, though it may be of questionable medical value. The major purchasers of EHR are large-scale enterprise hospital systems, and they, like the vendors, want to protect their investments so they take incremental improvements. They also practice… Read more »

John Haughom, MD
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John Haughom, MD

I wholeheartedly agree with Dr. Wah’s assessment. After spending 20 years trying to implement these systems into the complex clinical environment, I am well aware of the issues and the frustration they cause among clinicians. Usability is a very big issue and it will need to be advanced along all of the fronts outlined in his excellent article. It all boils down to paying careful attention to identifying optimal workflow and thoughtfully implementing the systems into that workflow. In truth, this was probably not possible even a few years ago, but with the advances in technology, I believe it is… Read more »

steve
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steve

All EHRs are designed for administrators. If anyone ever designs one for practitioners we might actually like them.

Granpappy Yokum
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Granpappy Yokum

“I am glad that the AMA is going to bat for this. We need them to be louder, clearer, and more forceful.”

Well, my reaction on reading their paper was more along the lines of “Yeah, and if I were a unicorn, I’d fart rainbows.” They’re still stuck in the fuzzy, unfocused, trying not to step on any toes thinking that got us into this mess.

Joe Flower
Guest

Timely and important. I am glad that the AMA is going to bat for this. We need them to be louder, clearer, and more forceful. The trouble is that for the most part, the people making the real buy decisions on all these new EMR and enterprise software systems are executives of large healthcare organizations. They are mostly not doctors, and typically do not seriously involve their doctors in the design details (unlike Kaiser, who involved the docs broadly, deeply, and over the entire design process). They are also not usability experts, and have difficulty recognizing the problems that are… Read more »

@BobbyGvegas
Guest

“Collaboration means standardization”
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Yes. See my current post at Blog.KHIT.org (which cites Dr. Carter’s latest EHR Science post, along with my longstanding “Interoperababble” rant).

Saurabh Jha
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Saurabh Jha

Good read, but depressing.

What you are saying is that we have not even standardized the language that enables algorithms.

Perhaps EHR is still before its due time.

Saurabh Jha
Guest
Saurabh Jha

The general approach to getting the right design is by trial and error. Usually this is done by the wolves in the market. They know when people are not happy with the design because no one buys their product. Sometimes, they fail because the design is ok but the users are a finer market than they had anticipated (e.g. self indulgence and segways). Apparently someone woke up one morning and came up with a stunning insight – we need to collaborate. Well, why didn’t I think of it, eh! EHR is not central planning’s first serious experiment (that was in… Read more »

Jerome Carter, MD
Guest

Yes, usability is an important trait of good software. However, current EHR systems are doing exactly what they were designed to do. Current EHR systems were conceived as electronic versions of paper charts. Paper charts are passive; they do not assist in patient care. Rather, they exist to provide a record of what has occurred. Using the paper chart as a design guide resulted in electronic systems that emulated their paper forebears. Thus, EHR systems are geared toward data collection and reporting. EHR systems do not contain models of clinical work. They do not have user-configurable workflows. They are not… Read more »

Granpappy Yokum
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Granpappy Yokum

” Perhaps it would be better to start from scratch using clinical work as the design paradigm”

What do you think the chances of that are?

An EHR actually based on the paper chart would be a HUGE improvement over what we have now, the misbegotten love child of billing software and MU.

Jerome Carter, MD
Guest

The chances that current market-leading EHR vendors will start from scratch is close to zero, and I do not expect them to do so. In any domain, companies that are heavily vested in the status quo rarely are the ones that are the first to market with radically different solutions to old problems. The first clinical care system that intimately supports clinical work will be built by a company that is now currently quietly watching the MU mess, listening to clinician complaints, and imagining how to address the issues raised with modern mobile, cloud, and workflow technology. When the first… Read more »

Granpappy Yokum
Guest
Granpappy Yokum

Thanks for the reply.

Will clinicians/organizations have the financial reserves to ditch current systems and try something new?

Jerome Carter, MD
Guest

Switching will be based on the degree to which changing systems will result in noticeable benefits. If the benefits, however measured, are minor, then the cost of changing will not be worth it. However, if they are significant, then changing will pay off over some period of time.

LeoHolmMD
Guest
LeoHolmMD

Good points. Technology has a history. It seems like some learning should be happening where the same mistakes are not made over and over. I feel like we will be stuck with Pac-Man for a long time. Unlike getting a new phone these days, changing EMRs is a terribly painful process.

Jerome Carter, MD
Guest

You are correct. Changing systems is painful, yet surveys show that many are considering doing so.

@BobbyGvegas
Guest

“After all, building from scratch is cheaper and less problematic than renovating.”
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I could not agree more. Let’s start with a comprehensive “Data Dictionary Standard.” Blog.KHIT.org

Jerome Carter, MD
Guest

A data dictionary standard or a standard data set, which might well be the same thing, would be a good start.

http://ehrscience.com/2014/07/14/building-clinical-care-software-systems-part-i-issues-and-challenges/

@BobbyGvegas
Guest

That is indeed my argument, and yours, essentially.

@BobbyGvegas
Guest

I would argue that it’s fundamental. The reason that math WORKS — algorithmically — owes at root to the uniform standardization of what the symbols (including the operators) MEAN (the “metadata”). With respect to the “math” that is EHR programming, on the non-integer/rational number side of things in particular, the lack of strict standardization and the random variability among the metadata inevitably begets the interoperababble that dogs our efforts to this day.

@TonyJewell
Guest

When I worked at HHS from 2001-05, Secretary Thompson was extremely frustrated by the slow adoption of EHR and other health information technologies. We went to an ATM in Russia and he noted, “I’m in St. Petersburg and this bank can tell me exactly how much money I have in my account in Elroy, Wisconsin. But if I had a heart attack, doctors here would have simply no clue of my health history. None.” While steps have been taken in the last decade, real world medical practice -and the frustration of AMA and its members – show that so much… Read more »

Granpappy Yokum
Guest
Granpappy Yokum

“Usability should be the driving quality of all health IT”

Good point, but maybe that should have been addressed, oh, about twenty years ago . . .