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

28 replies »

  1. “The most amazing failure of the EHR is the lack of standardized format and readability of one EHR data in another”

    See my Blog.KHIT.org. Current post.

  2. “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.

  3. 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 records that are as useful and as available as a patient’s bank accounts. This isn’t a cure-all, of course, but it is a welcome addition to the efforts to benefit patients.

  4. 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.”

  5. 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 faced with issue with the digital output from scanners – which were initially all proprietary. We forced the manufacturers to adopt a single standard called DICOM that allows the output from any scanner to be read with the same software. And there are multiple different free DICOM reading softwares out there today. Contrast that with the inability, absent a expensive custom interface, for one EHR to read data from another.

    The only thing that makes any sense is that the manufacturers/developers paid off the Feds (via campaign contributions, etc) to ensure their revenue stream. Other than that, the level of stupidity/poor planning is mind boggling.

  6. 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.

  7. 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???

  8. 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 the “You go first” so that others can figure out the mistakes and bugs in the system before they pay for unproven technology. That’s why Kaiser went with EPIC off-the-shelf instead of continuing to try to develop their own EHR system.

    Also, I believe the the biggest and unstated problem for entry into the enterprise EHR system field is the health data legacy problem. Bringing the old health data forward into a different system, even a different instance of EPIC, is a difficult task which most systems will be loathe to attempt except as a last resort.

    You want to overhaul EHRs? Then, please start with the premise and promise that your work is “To Make Healthcare Easier” and I will be onboard. Otherwise, I need to go type more notes into the chart to satisfy some coder.

  9. 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 getting to be much more of a possibility. The key will be vendors who are willing to make the investment and effort to work with experienced clinicians who understand these issues well. I appreciate the efforts of Dr. Wah and others to make progress on this front. It is necessary and overdue.

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

  11. 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.

  12. “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.

  13. 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.

  14. 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.

  15. 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 being built into the product. Most importantly, they have gotten where they are by being pretty good at running a healthcare system the old way — transaction-based, code-driven fee for service. They have trouble seeing the new way in detail, much less seeing the demands that puts on their enterprise software for transparency and portability of data and usability across multiple interfaces.

    Here is my advice to most healthcare executives: Start over. Seriously. Yes, you may have just spent sums that would make a hedge fund manager drool and go weak in the knees, all on enterprise software and an EMR and CPOE system. But if the software system does not help your doctors work more efficiently, help you forecast your shifting financial situation in the increasingly hybrid world of the Next Healthcare, provide you with deep and continuing insight into your system, enable you to communicate with intersecting systems, and help you target the most vulnerable populations for extra help — junk it. It is getting in your way at a time when you need all the help you can get.

  16. Thanks for the reply.

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

  17. 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 product is released, current EHR vendors will insist that the new product really isn’t that different in functionality from their products. Word of mouth will get more clinicians to try the new products, and by the time current vendors realize the new systems really are different, they will be 2-3 years behind.

    This is the way technological advances occur.


  18. “After all, building from scratch is cheaper and less problematic than renovating.”

    I could not agree more. Let’s start with a comprehensive “Data Dictionary Standard.” Blog.KHIT.org

  19. “Collaboration means standardization”

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

  20. ” 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.

  21. 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 Moscow some 80 years ago). But it may be its most defiant failure.

    And so we have committees that advise on “frame work for success” where Apple just prefers marketing.

    Collaboration means standardization, which means imagining the epidemic of ways privacy can be breached (you’d think HIPAA was designed to protect identities of Al Qaeda double agents). Oh, whilst you are there can we obtain thousands of pieces of information so that we manage population health.

    Hayek would have said: told you so.

  22. 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 aware of the cognitive needs of users, and they have no representation of collaborative care. No, they are what they were designed to be: electronic repositories of patient data. And, since the advent of MU, they have become even more focused on administrative and regulatory requirements.

    I am greatly encouraged to see a medical professional organization take an active role in creating software that supports clinical care delivery. However, turning an electronic data repository into a clinical care system that intimately supports clinical work is going to be a huge renovation project. Perhaps it would be better to start from scratch using clinical work as the design paradigm instead of the paper chart. After all, building from scratch is cheaper and less problematic than renovating.



  23. 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 more needs to be done.

    Will the AMA have a galvanizing effect and get all of the players to play together? History says “meh,” but they are to be commended for taking a leadership role.

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

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

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

    Yes, of course, but we ask too much of even the best EHR software when we try to shoehorn all the voluminous requisite data I/O tasks (potentially hundreds of variables or more per patient) and the cognitive (dx) tasks they feed into the 20-30 minute patient encounter that is the overwhelming norm for keeping the doctor’s office in business.