While early adopters “are well known to tolerate imperfections,” at this point in the Internet age and in the Meaningful Use program, EHR design will need to evolve to meet clinicians’ needs, according to acting national coordinator for health IT Jacob Reider, MD.
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,” Reider wrote on the ONC’s blog, bringing to mind varying complaints from clinicians — dozens of forms to fill out, hundreds of screens to click-through, cluttered menus and irrelevant notifications, in addition to data exchange limitations.
“This is a problem,” Reider wrote. “Traditional market forces generally keep products that are difficult to use from succeeding, and as any user of an Apple Newton remembers, the promise of an innovative solution isn’t always realized and will/should fail in the marketplace."
Why haven’t poor EHR systems done likewise? As Reider noted, some critics contend that the government’s role in incentivizing the use of EHR’s also removed or diminished the type of market forces that would keep unusable systems from being available for long.
“[S]ome 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.’”
[See also: The year ahead in health IT policy.]
That said, he argues, “Health IT is not the same as consumer electronics.”
For one thing, the EHR user “isn’t always the buyer” — hospital and practice leadership usually make the final call (although some might let staff vote on various options). “This causes usability to be a less significant component of buying decisions,” Reider acknowledged.
For another, multi-year contracts for EHR software and so-called technical lock-in “cause portability to be a true challenge,” wrote Rieder, a former Allscripts CMIO. “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.”
On the other hand, the so-called legacy software operating in a high-risk setting will “evolve slowly” “for good reason,” Reider argued. “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.”
Also, he wrote, “systems are complex and require local configuration,” with well-designed products leading to “terrible user experiences.” The end user, a physician who might be weighing the costs and benefits of early retirement versus what s/he may see as pure administrative burden, has “no way of knowing who is responsible.” Was it “the IT department or the software developer?” or “Boeing or United Airlines who made these seats so uncomfortable?”
Rieder seems to have a “know it when I see it” feeling that there is “something more complex about enhancing/defining/recognizing usability in Health IT.”
At the same time, Rieder, a one time Apple programmer in the 1990s, thinks that the status quo isn’t acceptable, and that the government has a role to play, not in mandating designs but “guiding the health IT industry toward more consistently incorporating usability.”
In some cases, that requires working with stakeholders like family physician and usability advocate Jeff Belden, MD, who founded the website TooManyClicks.com, as a way to “think critically about how we develop health IT systems, and question assumptions about the best path forward,” Rieder wrote.
Citing Steve Jobs, Rieder said that “Belden reminds us that we need to carefully consider the clinician’s native workflow in the optimal design of an EHR process, and “that usability is just a milestone along the continuum from functional to meaningful design.”
As for the federal government’s advancing that continuum, Reider said the ONC is “working hard to both understand these issues and define an appropriate balance for the government’s role,” based on public input, Institute of Medicine recommendations and the ONC HIT Policy Committee.
Rieder also pointed to two new requirements in the 2014 EHR certification criteria for quality management and usability and safety, and the ONC is funding work at the University of Texas at Houston to develop better HIT usability evaluations, guidance for developers and examples of simplifying complex tasks.
And as Rieder re-assumes the position of ONC chief medical officer, Karen DeSalvo, MD, New Orleans’ former health commissioner and the designer of the city’s patient-centered medical home project, is taking over on Jan 13, 2014.
See also:
10 things to know about incoming ONC chief Karen DeSalvo, MD
