Column: A Quiet Revolution in EMR Usability

Recently, Shahid Shah, CEO of Netspective Communications, argued in this journal that physicians have shied away from electronic medical records (EMRs) because they have a negative impact on productivity.¹

“It’s not about the money… money being thrown at physicians won’t solve bad [EMR] design,” said Shah, who was referring to HITECH, the federal government’s incentive plan to accelerate their adoption. “If vendors respected service and product improvement as much as chasing new sales, [they would produce] minimally time-consuming software.”¹

Shah’s summary of the user experience with legacy EMRs is spot on. In fact, he may have understated the problem. Poor usability associated with legacy EMRs not only reduces physician productivity, it can harm patients as well.²

Scores of reports on file at the Food and Drug Administration (FDA) prove that poor EMR usability can injure or kill patients. In one case, a hospital worker’s misinterpretation of a tiny font on an EMR screen led him to dispense ten times the prescribed dose of a medication. The error caused the patient to have a heart attack.²

In other instances on file with the FDA, “user unfriendly interfaces” and “extraneous and distractive” information caused pharmacists to miss changes in medication orders. In one case, the result was a “life threatening acute asthma attack.”³

Nevertheless, I remain optimistic that EMRs will soon achieve their potential to improve quality and efficiency in health information documentation. In fact, they are well on their way to doing so.

Improving EMR Usability

Let’s be clear. Legacy EMR vendors know their products have usability problems. In fact, Healthcare Information and Management Systems Society (HIMSS)—a legacy vendor trade group—said as much in its recent Task Force Report3 on the subject, the principal conclusion of which was:

“EMR adoption rates have been slower than expected in the United States, especially in comparison to other industry sectors and other developed countries. A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available.”³

Yet, according to an Agency for Healthcare Research and Quality (AHRQ) funded study of certified EMR vendors, formal usability testing procedures, employment of user-centered design principles and specific resource personnel with expertise in usability engineering are not common among EMR vendors.⁴

Why would EMR vendors fail to improve the usability of their products when it appears to be in their best economic interests to do so? Are technical challenges too great given the 80’s and 90’s vintage IT architecture underlying many legacy EMR products? Do they worry that their customers will balk at the costs and operational difficulties associated with updating disparate servers and re-training users?

Certainly the reason cannot be that physicians’ cognitive workflows, or workflows of health systems in which they function, are too complex to permit significant improvements. We know this cannot be true because companies whose products support similarly complex workflows in other industries, such as nuclear power and aviation, have made stunning advancements in the usability of their products in just the past decade.

As McKesson’s Beth Meyer points out, “the cockpit of a jet airliner looks fundamentally different today than it did 10 years ago. [It] is easier to learn, more intuitive and – as a result – safer to use. Doing the same for health IT is critical.”⁵

Whatever the reason for the ongoing usability problem in legacy EMR products, some argue that the matter represents a market failure necessitating regulatory intervention. In its recent report on EMR usability for example, the AHRQ concluded that usability should become part of the certification test for EMRs.^4,6

I disagree. Regulatory intervention, whether it is overseen by the Office of the National Coordinator (ONC) or the FDA, will be terribly expensive, and it has no chance to impact EMR usability for the next five years; a critical delay given the government’s aspirations to foster rapid dissemination of EMRs via HITECH.

Do you doubt that regulatory intervention will be associated with a five-year lag before usability improves? Have a look at what AHRQ did after recommending this strategy. It commissioned a project, in conjunction with the National Institute of Standards and Technology (NIST) and ONC, to develop, test, and distribute EMR usability standards that vendors could use to evaluate their systems.

Aside from the fact that such standards would be non-binding; federal agencies are woefully understaffed and focused on other matters at the moment. And factoring in required public comment periods and sundry delays, it would be at least two years before the standards could be completed. Add to this a staged implementation of the standards, similar to what we’ve seen with the ONC certification criteria for EMRs, and you get the picture.

Aside from the delays themselves, the likely outcome of a regulatory process would almost certainly be criteria that are broad and bland enough to accommodate the spectrum of legacy EHRs on the market. That’s not even considering the flood of potential legal challenges that would threaten to countermand any useful criteria already promulgated.

Can a Market Strategy Work?

A market strategy can work if Shahid Shah’s assertion that providers haven’t adopted EMRs because they are unserviceable is correct. Prospective EMR buyers should compare usability across EMR products, especially some of the newer Web-based products, and factor their findings into their buying decisions. Which system allows you to order medications most quickly? Which one allows you to create the most elegant quality reports, share your records with other providers and look up lab results in the most intuitive fashion? Which vendor responds to your questions most quickly? Which vendor has the best track record for implementing user-generated suggestions?

A combination of newly available, Web-based, user-friendly EMRs and customers that demand such products is the most efficient way to improve EMR usability and assure these products achieve performance levels that our patients and, indeed, the entire health system needs.

Glenn Laffel, MD, PhD
Sr. VP Clinical Affairs
Practice Fusion EMR
www.practicefusion.com