Usability of EHRs remains a priority for ONC

The New Year is a time of reflection and anticipation. We reflect on what went well in the past (and perhaps what didn’t go so well); we anticipate future challenges and accomplishments.  

As I reflect on the past, I can see that we’ve accomplished incredible things together.  The majority of care provided in United States hospitals and medical offices is conducted with the assistance of information technology. Our care is safer, more efficient, and provides research and measurement opportunities that were simply impossible with paper systems.

But as a physician who has used an EHR in my clinical life since 2001, I worry that some of the usability challenges that we early adopters tolerated “for now” (a decade ago) remain unresolved.

This is a problem.

Early adopters of technology are well known to tolerate imperfections. Traditional market forces generally keep products that are difficult to use from succeeding, and as any user of an Apple Newton External Links Disclaimer remembers, the promise of an innovative solution isn’t always realized and will/should fail in the marketplace. Yet some have argued that the meaningful use incentive program altered market forces in a way that prevents well-intentioned products from failing as did Apple’s first “personal digital assistant.” Health IT is not the same as consumer electronics:

a)    The user isn’t always the buyer.  This causes usability to be a less significant component of buying decisions.

b)    Multi-year contracts and technical “lock-in” cause portability to be a true challenge.  One can’t just walk away from an EHR that’s not performing as expected.  Buying an EHR is more like buying an airplane than a clock radio.

c)     Legacy software in a high-risk environment will evolve slowly – for good reason.  One can’t change workflow or user experience too quickly, as changes in the user interface can increase error rates even if the new design is better for new users.  Errors can harm or kill people.  Developers need to evolve user experience slowly and carefully.  Usability won’t improve overnight.

d)    Health IT systems are complex and require local configuration. Inadequate local resources can cause well-designed products to offer terrible user experiences. To the end-user, they have no way of knowing who is responsible – the IT department or the software developer? Was it Boeing or United Airlines who made these seats so uncomfortable?

Do “I know it when I see it?“ External Links Disclaimer or is there something more complex about enhancing/defining/recognizing usability in Health IT? How does the usability of HIT products have an impact of the quality and efficiency of care delivery? How can we help make HIT products more usable? What is usability?

The (ISO) definition of usability, referenced in the 2009 HIMSS usability primer External Links Disclaimer is a good start:

“Usability is the effectiveness, efficiency and satisfaction with which specific users can achieve a specific set of tasks in a particular environment.  In essence, a system with good usability is easy to use and effective. It is intuitive, forgiving of mistakes and allows one to perform necessary tasks quickly, efficiently and with a minimum of mental effort. Tasks which can be performed by the software (such as data retrieval, organization, summary, cross‐checking, calculating, etc.) are done in the background, improving accuracy and freeing up the user’s cognitive resources for other tasks.”

About a decade ago, I was a young(er) family doc, helping physicians in my community learn about how to select and implement an EHR. This was a new domain for them, but they were engaged and enthusiastic. Asked to present the bullet list of criteria that they would use to select the best EHR, I often responded with the list that one would expect:

  • Write Notes
  • Write Prescriptions
  • Write Orders
  • Write Messages
  • Manage Lab results

But I knew this list wasn’t complete. The missing (and perhaps most important) bullet was usability. Here’s External Links Disclaimer a version of some guidance to my local colleagues circa 2005 that includes the term “usability.” “Are you kidding?  Usability?” They asked me after the presentation. “Did you invent a new word?”

In a former life – I had been a software programmer – writing software for the Apple II and then the Apple Macintosh. Apple had a user experience evangelist External Links Disclaimer, and user interface guidelines External Links Disclaimer with which all developers were expected to comply. The guidelines were very clear about the choice of font, order and location of menus, location and position of “help” balloons and so on. Here’s an example of a simple suggestion on how error messages can be more helpful from Apple’s 1995 edition:

An example of a bad message and an example of a helpful message

Select the image for larger view

Note that the advice here is to focus on the user. What does the user need to make the best decision?

While Apple was clearly a pioneer in making computers easier to use, the science of user experience and usability wasn’t new in 1982, and it certainly isn’t new today.  Electronic health records are tools that help clinicians do their work, just as websites are tools that help people do work, communicate, etc. Are you developing a website? If so – you can review the great resources available at usability.gov to help you make it more usable.

While the science of user interface design has come a long way since the early 1980′s, the basic principles are the same: focus on the needs and expectations of the person who is using the software. What do they need? When will they need it?  How can we help them complete their tasks with the greatest accuracy and the least effort? What are the assumptions External Links Disclaimer that we are making about the user’s workflow or goals?

Consider the expression of lab results. The way that most computer systems report lab results to both providers and patients hasn’t changed in over 20 years. It’s hard for us to tell – at a glance – what’s normal and what isn’t. It’s hard for us to explain to our patients what requires action and what does not. This wired article External Links Disclaimer from a few years ago expresses some of the great opportunities we have to evolve this “last mile” problem in the delivery of information to both providers and consumers.

Obviously, this simple example shows that with extra effort, the abnormal results stand out, making it easier for the provider to take action, and for the patient to understand and collaborate with the provider toward a shared decision.

We know that no software is perfect, and therefore no EHR is perfect. Like the airplane cockpit, the EHR is a complex instrument, to be used by highly trained professionals to perform complex tasks. Any errors in execution of these tasks could be deadly.

Government’s role.

While the usability.gov website provides ample guidance, there is no federal regulation that a website developer incorporate this guidance into their design – nor should there be.

Is health IT different? These systems – if well designed – guide users toward more efficient, safer, better care. If poorly designed, the user may be frustrated or confused, and could make errors that result in patient harm.

Working with experts in the field, we have been guiding the health IT industry toward more consistently incorporating usability into the “bullet list” of expectations above.

  • Working with our partners at NIST, we have hosted three annual conferences on usability over the course of the past three years, where we gathered industry experts, health IT developers, provider and patient advocates, and representatives of other federal agencies to learn from each other and provide guidance to the ONC.  Artifacts from these meetings are available here.
  • ONC’s HIT Policy Committee has hosted two hearings on EHR usability.  Here’s a link to the testimony of the hearing in 2010 External Links Disclaimer, and here is a link to the hearing in 2013.
  • ONC commissioned the IOM’s report on Health IT and Patient Safety, which includes several recommendations for how health IT usability is an important part of safer care delivery.
  • ONC’s 2014 Standard and Certification Criteria include two requirements in the domain of quality management, and usability and safety.
  • ONC has funded the work at UT Houston under the SHARP C project to develop:
    • Tools External Links Disclaimer for usability evaluation
    • Guidance for HIT developers as they begin to incorporate usability into their development lifecycle
    • Examples External Links Disclaimer for how health IT developers might make complex tasks like medication reconciliation easier and more accurate.

What’s next? 

Enlightened providers like family physician Jeff Belden External Links Disclaimer and “passionate design expert” Stephen Anderson External Links Disclaimer help us think critically about how we develop health IT systems, and question assumptions about the best path forward. As Steve Jobs once said, “it’s not the customer’s job [to figure out how to best design a system].” Belden reminds us that we need to carefully consider the clinician’s native workflow in the optimal design of an EHR process. Anderson’s complex model reminds us that usability is just a milestone along the continuum from functional to meaningful design.

We are working hard to both understand these issues and define an appropriate balance for the government’s role in helping evolve health IT toward better efficiency and safety through enhanced usability. What do you think?  We encourage your comments and suggestions.

 

12 Comments

  1. R Troy says:

    My background is in Financial IT. About 20 years ago, I was hired by a bank I was hired by a bank where my first task was to rewrite a system that bankers refused to use. It included all sorts of bizarre codes and commands that as a programmer I found baffling. Oddly, my orders were to write a new system that would work just like the rejected one. The requirement was to rewrite but keep the unusable GUI.

    I said no – I rewrote the GUI without a single ‘command’ – it was intuitively menu driven, and the bankers accepted it. Point being – I designed it to be usable to people who had come to hate computers.

    I’ve watched a fair number of doctors struggle with their EHRs. I knew one who has a part time single practice and refuses to get an EHR because the one her hospital uses is horrific to use, and very wasteful of time. An orthopedist I know loves what his system can do, but he is baffled by how badly laid out it is and why it forces one to answer absurd questions – such as the pregnancy status of a male patient.

    MU is very important, but GUIs need to be easy and consistent to use. Since so many are not, doctors in many practices still work off paper all day, and let staff enter it all in after hours. This isn’t the only problem in EHR’s, but it should be at the top of the MU list.

    One more thought; part of why the EHR world is so messed up may be that it doesn’t learn anything from the Financial IT world, which has been through most of the same basic issues for many years. We know security, privacy, connectivity between systems, letting customers have access to their data. However, ONC and the Health IT world act like this is all something new and that they can’t learn from the outside. This is amazingly small minded and a big part of the problem in the Health IT and EHR world today. No matter how much Financial IT people can bring to this world, we are blocked out because we don’t have ‘clinical experience’. ONC had a program that was supposed to rectify this, but the program was, IMHO, a huge mess, including a complete lack of follow-up for the people who went through the program to actually connect to the HealthIT world for employment.

  2. Bob Coli, MD says:

    It is encouraging to see Dr. Reider publicly acknowledge the industry-wide usability and interoperability problems in efficiently reporting, viewing and sharing the cumulative results of the more than 7,500 available patient diagnostic tests.

    Each year in the United States, the results of tens of billions of clinical laboratory, imaging and other tests are accumulating in increasing numbers of ambulatory and inpatient electronic medical records. The basic clinical data management problem is that existing EHRs, PHRs and HIE platform portals are still using an antiquated user interface with variable reporting formats that display results as incomplete, hard to read, fragmented data. Diagnostic tests represent an estimated 75 percent of the objective data inside all three health IT systems, but none have yet designed a human-centered user interface that helps both clinicians and patients efficiently view and share cumulative results over a lifetime of diagnostic testing.

    Fortunately for both physicians and patients, a growing number of physicians, health IT industry experts and patient safety advocates are recognizing that users of existing EHRs are “increasingly not seeing the big picture of a patient’s care due to information being ‘hidden in plain sight’, i.e. behind a myriad of computer screens where it is not easily aggregated into a single picture.” (1) Most physicians will agree with Dr. Dave Denton, one of many professionally active clinicians who are frustrated and unhappy in struggling with “poor graphic user interfaces that make it hard to see patient data in a way that makes sense and helps patient care.” (2)

    Ultimately, enabling the efficient viewing and sharing of scattered test results data will require the development and adoption of a clinically intuitive, standard reporting format that can display all results as integrated, actionable information. Solving this “last mile” problem in the delivery of information to providers and consumers will finally overcome a major usability and interoperability challenge. By meaningfully engaging patients and their families and improving patient safety, care coordination and quality, it will also support the five broad goals of EHR Meaningful Use. (3)

    1) http://hitechanswers.net/improving-use-of-health-information-technology-in-the-clinical-setting

    2) http://informationweek.com/healthcare/electronic-medical-records/why-doctors-hate-ehr-software/240162854

    3) http://nationalehealth.org/HITWeek-Standards

  3. Clayton Curtis MD says:

    Thanks for a thoughtful and very well-written article! I have observed organizations (including my own) tending in some quarters to take “usability” only in the strictest sense of human factors / interface design rather than in the sense of the ISO definition or “utility / usefulness / enabling power”. Clinicians want tools (including health IT / EHR) that let them deliver good / safe / high quality care in an efficient and effective manner that makes optimum use of time and money and doesn’t destroy any possibility of non-work life.

  4. Jorge Ferrer says:

    Dr. Reider highlights that next-generation EHRs need to focus on the attributes of usability that enhance the performance of the end-users. Capturing the patients story and filling in clinical knowledge gaps are two components of an EHR that will need to mature for the technology to enable improved clinical care.

  5. Art Swanson says:

    As usual, Dr. Reider provides a clear and concise definition of the current state of affairs and a pragmatic viewpoint on the path forward. The role that ONC has played in facilitating the discussion between the stakeholders as well as funding research into some of the underlying issues has continued to drive usability improvements in HIT. Having been actively involved in these discussions over the last 3 years, I can see the progress that has been made. There is a great discussion going on about User-Centered Design processes and how best to execute those in HIT, we have had some strong research and design guidelines published via the Sharp-C grants, and there has been a number of targeted design competitions to spark innovation and orthogonal thinking about design challenges in the industry.

    However, I am certain that our work is not even close to finished. As we have been focused on the usability issues with HIT applications from some of the most basic human factors perspectives, technology has continued to progress at a breakneck pace. The HIT industry is being affected by technology trends including mobile applications, multi-device workflows, speech recognition and natural language processing, big data and analytics, and even new computing platforms like Google Glass. We have also been working on Population Health Management and workflows required for accountable care organizations to more comprehensively address patient care plans and general wellness. These will introduce new usability issues that need to be effectively addressed, but will also introduce new options to address usability issues in existing applications. Usability is a process and not an outcome – because it can always be improved.

  6. Lana Lowry says:

    NIST has developed a usability / safety framework (NIST Interagency Report 7804 http://www.nist.gov/healthcare/usability/index.cfm.)
    This framework clearly distinguishes between usability aspects that pertain to user satisfaction and usability features that impact clinical safety. Limited critical usability aspects that pertain to the clinical safety must be embedded into the system and must be required as core functionality; a “barrier to entry” to the marketplace on safety is an expected outcome. Typical measures for clinical safety are adverse events (wrong patient, wrong treatment, wrong medication, delay of treatment, unintended treatment). Accepted usability/safety standards should be harmonized and considered industry standard practices.
    Any EHR company can go above and beyond the basic standard; however the minimum standards for usability in safety enhanced design should be established and articulated to address patient safety.

  7. David Kauff says:

    Jacob –
    Thanks for a clear and thoughtful statement about the evolution and advancements in EHR’s. I am thankful that the government (and hence you) are on this and can help navigate the future of how physicians, both young and old, navigate an increasingly busy and pressured clinical work life.
    At my organization, Group Health Physicians, we have about 1500 providers and have been using an EHR since 1994. We are both innovative – one of the first to use the computer for secure messaging and results reporting- and we dedicate a great deal of resources in helping our providers use the EHR well. Our internal research shows us that the efficient provider is a happier provider and we see fewer instances of medical error and unusual occurrences.
    Borrowing some innovation for Kaiser Permanente in Southern California, we have implemented a program that we run several times a year called Pathway to Proficiency (P2P). This is an intensive multiday ‘boot camp’ for all things EHR. It receives only the highest of evaluations and we cannot teach this enough. What we have learned over the years we have taught this is that ‘efficiency and safety ‘are two of the four goals we teach.
    The other two are proficiency and resiliency.
    We are learning that being proficient is a set of skills that are connected to and built upon efficiency. They are related and different. We want our Docs to have the skills, and more to have a way of thinking about using the tool more than knowing all the tricks and what all the buttons do. It is about teaching discipline in ordering, in communicating, in writing that makes the tool an ally and not an impediment to care.
    The second is being resilient – we are asking our providers – what skills do you have to right your ship? How do you successfully do all the stuff that is packed into the EHR and have a good life – go running, get home to do homework with your kids. You know – all of that. We are learning that the conversations about being good at the Medical Record is similar to how you talk about how are you being good in your life. We are adding more curriculums into P2P that asks our providers to figure this out. We talk about prioritizing work, time, and personal wellbeing. We even talk about literature and poetry that reconnects providers back to their primary job, to take great care of people. We are developing curriculum that acknowledges that we must ‘take care of the people who care for people’.
    It is my wish that as EHR’s evolve – from the Newton to the iPad with Retina Display – that the tools we build are designed to delight, and inspire and to remind those ‘ in the trenches’ ( sad phrase ) that what we do every day is perhaps one of the best professions on earth.
    I think you are on it Jacob. I do wonder how the EHR can evolve to keep Primary Care Providers from not being the first to retire – often years before their highly compensated specialty colleagues, and to help providers work more of the week – during the week and not the nights and weekends. Our research shows that by optimizing the people, right along with the technology, that people work better, are happier and patients get better care.

  8. Deborah Wells says:

    To quote the opening of this article “But as a physician who has used an EHR in my clinical life since 2001, I worry that some of the usability challenges that we early adopters tolerated “for now” (a decade ago) remain unresolved.” That’s OK because the whole healthcare experience has been “tolerated” by patients for decades. Now, that’s a problem

  9. Paul Latkany, MD says:

    Thanks for Dr Reider’s insightful overview.

    I sincerely hope improved usability becomes the next phase in EMRs. How can we enable continuously improving usability? How we can implement this immeidiately!?

    I have seen physicians quickly adopt dramatic changes in workflow to deliver optimal care to patients when improved therapies are developed. It is interesting to consider the needed lag in emr changes—even though the provider care workflow changes first. However, for instance, an interface on spot size for an improved type of medical laser delivery helped prompt the change in workflow. Could this interface have been even better?—well I think we all know that answer ;)

    Why can’t the multiple parallel efforts documenting workflow e.g. be mandated to populate and enable each other?

    If there is for example, workflow documenting a specific type of task of routine care in San Francisco, Chicago, Iowa City, Milan (Ohio), or Brooklyn—no surprise—that care is unlikely going to differ much (and likely will frequently not differ in any way–assuming you can ignore the difference in the accents :) There will be core steps and mostly minor variations around these core steps.

    How we do we best move this forward? Since the metrics of usability are mature, I think a strong argument can be made for simply mandating requirements.

    Supplemental support can be demonstrated by investigations into user satisfaction (patient and provider), user efficiency, improved outcomes etc.

    So if each of the ~850,000 physicians practicing in the US could vote and enable change in the EMR to improve usability (and a vote in favor of improving usability would be communicated by the word “Please!” -without any crass embellishments permitted).

    My vote would be cast as “Please!” If each physician would have a vote you would essentially have a document filled with ~850,000 words “Please!”

  10. Bennett says:

    Thanks to Dr. Reider for the fantastic post about usability and for sharing the various links to internet resources.

    We are very happy the usability is finally becoming “The New Black.” Usability in healthcare has a significant ROI, that is much more important than the typical 10to100x return — it might save a life!

  11. Stephen R says:

    Thanks Dr. Reider, this was a great post and very informational.

    There was a ton of resources in this post specific to the usability of EHR’s. I am having some issues with this exact topic in my office and I will be bringing this to them

    Thanks again,

    Stephen.

  12. Joe Bormel says:

    Thanks for a terrific post. I especially appreciated your going back to … the (ISO) definition of usability, … “Usability is the effectiveness, efficiency and satisfaction with which specific users can achieve a specific set of tasks in a particular environment.

    It’s the variations in the specific users, tasks and environments that cause many people to mistakenly conclude that usability is in the eye of the beholder. Clearly, usability is a well developed discipline with many extraordinary practitioners (many of whom you cited).

    The link you provided that shows “making complex tasks like medication reconciliation easier and more accurate” is a great example of objectively better usability design, and is quickly and succinctly captured on the two minute video on this page: http://www.cs.umd.edu/hcil/sharp/twinlist/index.shtml .

    The ONC-funded TwinList work exemplifies the dramatic improvements in usability possible when developers focus on specific users’ needs, specific task complexities, and tease out the ethnographic factors that have slowed our progress toward better healthcare.

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