Electronic health record (EHR) usability is the topic of this week’s Health IT Policy Committee hearing on April 21 in Washington, D.C. It’s an important topic that draws both a great deal of attention and diverse responses from the health information technology (health IT) stakeholders. Among other things, usability affects the efficiency of providers, the safety of the care they provide, and the cost of training and support.
Health IT is currently in a period of transition as the nation moves toward new expectations of functionality and performance under meaningful use. At the same time, expectations for IT, in general, are being raised to even higher levels – information must be interconnected, accessed via an understandable user interface, conveniently available, and ubiquitous. Certainly the level of user expectation for electronics and applications in the entertainment and social media world will push the development envelope in clinical and administrative settings. The way this world interacts and generates data and information is evolving – with inevitable implications for the workflow of health professionals who succeed and fail by the quality of available information.
We recently came across a news piece on bedside discussion, which illustrated how these implications are coalescing in a game-changing fashion. A physician and a person receiving care were using a tablet with access to the medical record and diagnostic images. The person said, “I finally understand my disease.” The physician said, “That is the most rewarding patient interaction I have had – it’s why I’m a doctor.”
This hearing will bring a wide range of individuals together to present many aspects of usability. A usability discussion is a multi-stakeholder one that requires developers, users, policy-makers, and patients. It requires innovators who would bridge the gap between what is and what can be. It requires participation from the usability experts – academics and analysts who have studied the field in and outside of health care. It requires those that would provide insight on how this nation can build a market around what we value in our technology, beyond functional requirements. As health IT evolves, we need to understand the potential of new levels of usability and the challenges of realizing it.
The solutions to our usability challenges rest not with any one stakeholder group. We cannot expect the developers to bear sole responsibility for a solution any more than we can expect a comprehensive policy mandate on usability to be successful. Usability is in the details and in all levels of structure, process, and design. There is not one single thing that makes it right or wrong. The solution will come from experiments and feedback and on-going evolution. The solution will also come from honest communication from all stakeholder groups and earnest planning to address a challenge that can determine the pace of technical evolution.
Come and join us in this rich dialog. We look forward to your participation. You may attend the hearing in person or listen via phone or computer. In addition, we welcome your comments on the blog post and will keep it open for comments until April 29, following the hearing.
Tags: FACA, HIT Policy Committee
Compliance with usability standards for EMRs will likely not be achieved with voluntary rules. Improved usability will probably not be realized thru market forces. There are situations where usability is certainly driven by the market. I switched from one email vendor to another vendor because of usability. When there are low barriers to market entry, low barriers to changing to a new EMR vendor (for a practice or hospital), and when doctors are the consumers of EMRS (not just the users), usability will be a critical factor that will lead the design and development of EMRs.
However, as we know, medical economics are much more complex. Barriers for entry into the EMR market are high (because of complexity), barriers to change EMRs within a practice or hospital are high (expensive). Doctors and other end-users will rarely be making purchasing for the EMRs they use. Hospital networks and large organization with complex needs will be making these buying decisions. Usability may not have the market moving power it deserves, and has in more elastic markets (like the choice of mobile phones or email systems).
We currently accept inefficiencies, poor human factor design, and unproven assertions in technology that would be quickly rooted out in other medical technologies and in other industries.
We need strong oversight to make sure that useful technology components and innovations do not find their way into clinical settings without baseline safety and usability requirements. Voluntary rules will likely be inadequate to achieve compliance with usability standards.
David Brick, MD
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Not sure if this is the same public comment period related to the Federal HIT Strategic Plan, but as the usability of EHRs is a critical factor in both venues, I’m reposting our official comment to Dr. Blumenthal’s March 28 post to the ONC blog here:
Successful integration of EHRs into the DNA of healthcare delivery will facilitate health information exchange on a global scale with the goal of improving both coordination of care and public health but only if those EHRs are shaped around standards and best practices for capturing and managing patient health information in a practical, patient-centric manner. As the ONC turns its attention toward the usability of EHR systems, it will be critical to define usability from two important perspectives:
• Usability of the EHR system – Does the system complement the diagnostic process and practical work flow of care providers? Or does the technology ask providers to compromise the care process to “fit” the system?
• Usability of the information – Does the EHR system facilitate the capture of care encounters in a way that generates truly meaningful information? Or will the critical detail of that care encounter be forced through an EHR filter that results in data that, while capable of aggregation and analysis, is of no practical benefit to or legal support for the provider?
At great risk of extinction in our pursuit of health information exchange is the patient health story. Every patient has one, and it’s more than just an aggregation of care “data.” It is the chronicle of every care encounter, treatment decision, clinical conversation, and health outcome in a patient’s life from birth to death. Preserving that story will be critical to capturing an information-rich care record for coordinated care and treatment decisions, facilitating truly practical adoption and integration of electronic health record (EHR) systems, and engaging patients in their own care story in a way that empowers them to make better health decisions and meet care compliance goals. And if the goal is a meaningful NHIN, then the story has to matter. The sum is greater than its parts.
We are in danger of losing this story in the EHR. Physicians and other care providers need the freedom to record as much detail as they feel necessary when documenting a care encounter with a patient. Many EHR systems are forcing physicians into point-and-click entry that is radically changing the way they document patient care, and many are complaining that restricted “data” fields in EHR systems are prohibiting them from documenting the way they need to. (See New York Times article The Doctor vs. the Computer – http://well.blogs.nytimes.com/2010/12/30/the-doctor-vs-the-computer/.) EHR systems should not ask providers to compromise either the care process or the way they choose to document it simply to “fit” the system. This is not, on any level, usability.
EHR systems must be required to interface with dictation/transcription systems. The dictation-transcription process remains the preferred method of physicians for documenting healthcare encounters because it is easy to use and is time-efficient, allowing physicians to focus on reconnecting with and treating their patients. By making the dictation-transcription process a required component of “meaningful use,” physicians will be more likely to embrace the push for greater EHR adoption and to find the experience of using an EHR to be a positive one for them, their healthcare teams, and patients.
Required data elements can be tagged and exported from information-rich narrative notes into EHR systems. Contrary to what EHR vendors are reporting, physicians do not have to give up narrative dictation in order to comply with EHR adoption goals. The healthcare documentation/medical transcription sector is already deploying technologies to codify narrative reports, using established clinical nomenclature systems like SNOMED, to tag data elements in those reports and export them to EHR systems to meet meaningful use, core measures, and other clinical reporting criteria.
In December of 2010 the President’s Council of Advisors on Science and Technology (PCAST) released and discussed its report entitled “Designing a Digital Future: Federally Funded Research and Development in Networking and Information Technology.” Per the press release of December 16, 2010:
“But achieving the full potential of health information technology will require the development and adoption of a robust information-sharing infrastructure to facilitate the exchange of data among institutions, the report concludes. Unlike conventional electronic health records, which are effectively digital versions of paper charts that are trapped in the offices where they are created, such a
system would allow health data to follow patients wherever they are, with appropriate privacy protection and patient control, while giving patients’ various doctors a more complete picture of those patients’ medical conditions and needs.”
If it is truly the goal of electronic health record integration and adoption to improve patient outcomes and quality of care as well as reduce the cost of care for the US healthcare delivery system, the considerations outlined here will be an important part of ensuring that health information, and not just health data, is the compelling objective. Narrative capture must be factored into the equation for generating a meaningful health record if the goal is to create one that truly provides that “more complete picture.”
You’ll find the position of the clinical documentation/medical transcription sector outlined in our official Comments on Meaningful Use Stage 2 (http://www.ahdionline.org/Portals/0/downloads/CommentsMeaningfulUseStage2CDIA_AHDI.pdf), submitted to HHS last month. We urge the ONC to make protecting the patient story a critical priority in these and future considerations of EHR standardization, integration, and usability.
Lea M. Sims, CMT, AHDI-F
Director of Professional Programs
Association for Healthcare Documentation Integrity &
Clinical Documentation Industry Association
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I have been a medical transcriptionist for 39 years, and have embraced many new technologies along the way. I have also had to upgrade my skills, my education, and my knowledge base over the years, to keep up with advancing medical science. I have gone to a great deal of trouble to become certified in my profession, and I have a robust skill set that I bring to the table.
It is simply not possible to tell the entire patient story with point-and-click and check-boxes. Those technologies are really only suitable for a completely negative review of systems or physical examination. Here is an example of why. Suppose the patient complains of chest pain, so that is checked off as positive in the system review. But how long has the chest pain been going on? Is it of sudden onset, or has it come on gradually? Does anything exacerbate or relieve it, and if so, what? Is it intermittent, or constant? What was the patient doing when it first began?
In other words, the patient’s chest pain story simply cannot be told with a positive check box.
This reminds me of a meme that made the rounds at the height of the popularity of the movie “Titanic.” The meme? “The boat sank.” Well, yes, it did, but there’s a great deal more to the story!
I am similarly reminded of the time that one of my former doctor employers, when asked what was wrong with a patient, simply answered, “Cancer.” Another doctor, in answer to a similar question, said, “She’s sick.”
One final anecdote. Many years ago, one of our workman’s comp patients put in a claim for payment for a hearing aid. Naturally, the insurance carrier questioned this; but after they had reviewed the complete narrative (dictated by the physician and transcribed by the MT), they understood that the medication prescribed to treat the patient’s work-related injury had the rare but well-documented unfortunate side effect of hearing loss, and thus paid for the patient’s hearing aid.
Thank you for your consideration.
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I have been a medical transcriptionist for a couple of years, and while I embrace the advance of technology and even look forward to it there is a need for a human to listen to the dictation and catch and “flag” any errors that we come across. The patient’s story cannot accurately be told without a system of checks and balances. Everyone is human, including the doctors or nurses that either dictate a report or enter the information into the boxes, and errors can be made and another set of eyes does improve the quality of the patient’s story. Meaningful use needs to include a correct and accurate story of each patient and their medical history.
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