In a Jan. 14 letter to National Coordinator Farzad Mostashari, MD, commenting on the Health IT Policy Committee's proposals for Stage 3 meaningful use, James Madara, MD, executive vice president and CEO of the American Medical Association, put forth some of the AMA's "concerns and recommendations" about the program.
Among the association's five complaints (see, "Industry airs Stage 3 'concerns,'" page14), was that, "More and more physicians are raising concerns regarding the usability of EHRs," Madara wrote. "More attention needs to be paid during the EHR certification process to address physician usability concerns."
Put more simply: Most electronic health records are ugly to look at, and they don't work all that well. It's not just a matter of aesthetics. Clunky interfaces are having a detrimental impact not just on the workflows of the clinicians who use them, but also on the willingness of those who aren't using them but might be willing to give them a try.
In an era of sleek and eye-catching iOS-esque design, most EHRs are cluttered and drab. Clinicians who've become accustomed to the intuitive user experiences offered by the Googles and Facebooks and Amazons of the world, are forced to use overpopulated and often confusing input screens when they're at work.
"There is a direct correlation between EHR adoption and the usability of an EHR," wrote Madara in his letter to ONC. And he cited a finding of the HIMSS EHR Usability Task Force, which suggested that "usability is one of the major factors - possibly the most important factor - hindering widespread adoption" of EHRs.
Functionally, a good electronic record should make for easy care coordination and point the way toward improved outcomes, the AMA letter argues. "The usability of EHR products should also support decision- making, not circumvent the need for critical thinking," wrote Madara.
We're not there yet, though. Too many EHRs are minefields of unexpected alerts, confusing data fields, and reams of unneeded information that could run the risk of obscuring the necessary clinical knowledge.
This isn't meant to hand out blame. As Roderick McMullen, a systems designer and UI specialist, wrote not long ago in Fast Company: "In defense of the software companies, their hands are tied in a couple ways. First of all, they have to sell these systems. If you don't present every imaginable piece of information to the physician, you'll lose in the marketplace. The competition will be able to say, 'We give you more information,' which leads the customer to think your product is less sophisticated.'"
Instead, vendors should be taking a more attuned and organic approach to conceiving EHR interfaces. Madara cites a 2010 AHRQ study that argued, "Driving the EHR market toward creation of usable products requires development of a process that accurately identifies usable products, establishes and disseminates standards, and encourages innovation."
On a policy front, Mostashari insists ONC is doing the right thing. Speaking recently to Healthcare IT News Editor Bernie Monegain, he cited projects such as its Strategic Health IT Advanced Research Projects (SHARP), and its work with National Institute of Standards and Technology.
"We have usability guidelines. We have certification requirements around user-centered design, transparency around user-centered design approaches," he said.
But when it comes to usability, Mostashari says the market should indeed be the driver.
"I don't see why fierce competition should not be occurring," he said. "If we look at products today, they're a lot more usable than they were four years ago, and I hope they're going to be a lot more usable four years from now - even things on the hardware side. The explosion of tablet use in medicine, I think, is having a tremendously positive effect on usability of the systems."
He added that perhaps it is time that vendors "focus on delivering not just more bells and whistles, but simplicating and adding lightness for a change."
Amy Cueva, founder, chief experience officer and healthcare principal at Portsmouth, N.H.-based user-centered design firm Mad*Pow, whose clients include heavy-hitters like Cleveland Clinic and Brigham & Women's Hospital, agrees.
Another of Mad*Pow's clients was McKesson, whose Homecare EMR was dogged by complaints about a user experience that was suboptimal, said Cueva.
"They realized they needed to give it a complete overhaul," she said. "The homecare EMR market is competitive. And as such, they needed to compete on user experience. The application was getting a bad rap with homecare nurses."
Mad*Pow did field research - traveling with nurses, home to home, to see what the care environment was like. "We saw that the system workflow did not match the workflow of the care experience, so the nurses were having to jump around to various screens to do things that should be right at their fingertips," said Cueva.
Its fact-finding process is directly in line with advice given by David Kelley, founder of the famed IDEO design firm, in a recent 60 Minutes profile. "If you want to improve a piece of software," he said, "all's you have to do is watch people using it and see where they grimace."
In the end, McKesson was pleased with Mad*Pow's improvements. In fact, the corporation even touted the fact that it had hired a design agency in its marketing materials, as if to say, "We get it."
Cueva is also the founder of the Healthcare Experience Design Conference (HxD), the third annual installation of which will take place in Boston March 24-26.
The conference aims to explore how "human centered design and design thinking can improve the quality of health service delivery and digital interactions," according to its website.
Nonetheless, "We don't have many speakers talking about EMR or EHR design or usability," said Cueva. "The fact is that the EMR and EHR companies really have not put a focus upon it and are not active in the community."
But they should be, she says, "as a step in the right direction toward human centered design and commitment to improvement."
Structured data and interoperability and all the other technical needs of EHRs are all well and good. And certainly no one envies that vendors must worry about incorporating an ever-expanding list of complex capabilities into their products in order to be certified for meaningful use.
But Cueva says design has to have an important place at the table. She suggests that vendors "put someone in charge of user experience" at the C-level - a chief experience officer, perhaps. "It needs to be elevated in the organization and considered in the process," she said. "EMR companies need to be visionary. They need to be thinking three and five years out, beyond the specific release cycles they're on and all the requirements they have to meet."
The MU incentives have done wonders to spur adoption, after all, but, "You don't have to pay people to use Facebook or Google or their iPhone," she said with a laugh. "They use them because they're valuable and meaningful and give them something they can't get anywhere else."
