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Friday, August 18, 2017

Some Thoughts On How To Ease The Usability Crisis With Electronic Health Records.

This appeared last week

Cerner's John Glaser: How to finally fix the EHR usability problem

The veteran executive proposes a multi-pronged approach to ending the tyranny of wasted time and effort created by today’s technologies.
August 09, 2017 11:09 AM
The HITECH Act resulted in near universal adoption of electronic health records (96 percent in hospitals and nine out of ten physician offices, according to the latest ONC tally) and having all that clinical information in electronic form is a remarkable advance. 
It enables a wide range of possibilities for improving care, assessing its value, and managing populations in ways that might actually improve our collective health and reduce the overall healthcare bill. On the most basic level, caregivers should have an easier time getting up to speed on each patient's history and current condition than in the old days where they had to thumb through a paper chart trying to decipher other physicians' handwriting. Moreover, this advance means that patients can become more active and equal participants in their care; they can use their phones to discuss healthcare issues with their care team and see when they last had a tetanus shot.
But this significant progress in adoption also gave rise to concerns about the usability of EHRs.  
Physicians are spending twice as much time with their EHRs as they do with patients, according to a time and motion study published last fall by the AMA. In the most recent Medscape Lifestyle Report, a survey of 14,000 physicians, EHRs were the fourth most common cause of burnout EHR complaints beat out insurance issues, threat of malpractice suits, concerns about salary, and patient volume.
EHR-induced patient safety problems related to usability are becoming a concern. A 2015 study published in the Journal of Patient Safety described almost 250 cases where EHR glitches or poor human factors were alleged to have caused patient incidents led.
Why have usability issues come to dominate so many discussions about EHRs?
First, change is hard, and EHRs are a big change, especially for clinicians who spent decades perfecting their use of paper charts. Any time you introduce new technology and new processes deep into the fabric of someone’s work routine, there will be significant struggles and bumpy transitions that might last years.
Second, if you're used to whipping off a prescription in five seconds, spending thirty seconds to enter the same information into the computer must seem like an absurd imposition, even if it does make the information exquisitely readable and simultaneously accessible to all authorized users. The same is true of many formerly paper-based tasks that now require clinicians to enter structured terms into fields. Those extra few seconds per task, multiplied by dozens of tasks, can add hours to the workday.
Third, the user interface design of EHRs can be sub-par. Compared with the smartphone tech we carry in our pockets, many EHR user interfaces feel like a throwback to the 1990s, and too many clinicians have tales of needing a dozen clicks to order a single drug, or being harassed by alerts to the point where they just ignore them all.
In fairness to EHR developers, automating healthcare tasks presents an exceptionally difficult design challenge. Medicine is based on a very complex body of knowledge, encompasses dozens of specialties, and tackles thousands of different diseases. Ideally it requires an application that can aggregate patient histories, lab values, medical images, monitor tracings, vital signs, progress notes, and miscellaneous other pieces of information, process them, analyze them, and send them back to the clinician with notes on best practices and relevant recent research. Compare that task to designing an application that supports the six transactions we might want to make at an ATM.
Fourth, in our collective efforts to improve care we have moved more and more work onto the shoulders of the clinician. Asking patients about the safety of their homes, engaging them in discussions about smoking cessation, counseling them about the importance of taking their medications, and documenting interactions using structured vocabularies ­– all of these actions could benefit patients. But their cumulative impact on a clinician can be overwhelming.
In some ways, beating up EHR vendors on usability is a form of shooting the messenger. Clearly the vendors have work to do, but others created the tyranny of large numbers of good ideas of work for the clinician.
What’s more, physicians often don't directly benefit from investing all this extra time.  It's legitimate for them to ask, "What's in it for me and my patients?"
The benefits of EHRs seem to accrue to the healthcare system as a whole, or to payers--not to physicians, unless their compensation is adjusted.
Eventually, a value-based reimbursement model should reward their effort, but that prospect probably seems very far away to most.
So, what can we do to significantly improve the usability of electronic health records? There is no single strategy or tactic that will address all these factors. 
-----
See the suggestions that follow.
John Glaser, Ph.D., is Senior Vice President, Population Health, of Cerner Corporation. Prior to this position he served as the Chief Executive Officer of the Health Systems Business Unit at Siemens. He is the author of several books including “Glaser on Health Care IT” published by HIMSS Books. 
The whole article is here:
Well worth  careful read I reckon.
David.

13 comments:

Bernard Robertson-Dunn said...

"EHR-induced patient safety problems related to usability are becoming a concern. A 2015 study published in the Journal of Patient Safety described almost 250 cases where EHR glitches or poor human factors were alleged to have caused patient incidents led."

So, what does the ADHA strategy say about safety?

"Digital communication will deliver significant benefits relating to the safety, quality and costs of Australian healthcare ..."

"People will be able to request their medications online, and all prescribers and pharmacists will have access to electronic prescribing and dispensing, improving the safety of our systems."

"Digitally-enabled models of care that drive improved accessibility, quality, safety and efficiency."

etc etc.

Any mention of the risks to safety? Not that I can find.

Is this a worry? Apparently, if you are ADHA, no.

Tom Bowden said...

Hi David,

In my view, making systems useable and truly useful is absolutely key to getting healthcare economies to transition to electronic systems.

This week I really enjoyed the video link:

https://www.youtube.com/watch?v=xB_tSFJsjsw&feature=youtu.be

We are far from alone in our frustrations with the challenges of introducing electronic systems.

Kind regards,

Tom

john scott said...

Tom, I enjoyed the video.

You introduce two perspectives that have not been the subject of much conversation.
The first is the role of the economy and how we think about economic matters in regard to service sectors like healthcare.

The second is recognition of the technology industry and implicitly the techno-economic platform concerns.

To the first, health remains caught up in the old economic paradigm of manufacturing and its concept of 'productivity'. Commonwealth Health has already recognized publicly that this way of seeing the health sector doesn't work. Services are about Mutuality, not about Maximizing the use of Scarce Resources. Having said that, the Commonwealth doesn't have a replacement--as yet. There is one, but they are not looking.

The second issue brings into question, at the very least, seeing the health sector as a whole and the flows of information within and across a range of boundaries. Shifting to this perspective is critical and will necessarily have significant implications for our conceptions of collaboration and governance structures as well as the medical software industry. Certainly it will mean moving away from the hospital-centric view that currently dominates State and Territory thinking.

Bernard Robertson-Dunn said...

John,
"To the first, health remains caught up in the old economic paradigm of manufacturing and its concept of 'productivity'."

IMHO, you've got it in one.

It started with the RAND corporation paper published in September 2005.

Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, And Costs
http://content.healthaffairs.org/content/24/5/1103.long

Bureaucrats, managers and politicians have held to that view ever since. It seems to me that a massive failure to deliver and a new bread of decision makers is what will be needed to change things.

Dr Ian Colclough said...

Tom, I have seen no clear evidence the ADHA apppeciates that let alone is prepared to provide funds to bring that about. Nor do I see anything that indicates they have a business plan which would achieve that goal.

Anonymous said...
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Anonymous said...

It doesn't matter how easy it is to use, if the data is bad, it will be useless, if not dangerous.

Anonymous said...

A whole floor at their Pitt Street Offices, for UI? The ADHA has the MyHR only, it is hardly eBay, a couple students working from home could manage that. Or is it some new eHealth Hipster drop in centre?

Also did Tim not lead everyone to believe that view of his was the first thing he would change as it was not a good look?

Look forward to see the year end report from the board.

Anonymous said...

5:43. Good user interface design should start with stakeholders guiding the information design and then interaction layer. It will be rather challenging to do much without rethinking the information design.

Anonymous said...

Stripped out and refurbished a whole floor, spared no expense? Well anyone would be forgiven for thinking they are running a private UX consultancy firm up there in Sydney. What exactly is it that will be launched? Is it the refurbished floor that will be launched? Will there be champagne?
Some pretty colours, funky fonts and new screen layouts, and a champagne launch - now that's a strategy for fixing the national EHR!

Anonymous said...

When almost $2 billion health dollars has been spent on a questionable contentious IT project with no independent monitoring or review at all health professionals should be demanding an enquiry.

Anonymous said...

Such enquiries are meaningless and self-serving when the Health Department is involved in setting them up. Independence and probity can only be assured when the Auditor-General is involved.

Dr Ian Colclough said...

I find it very difficult to believe 5:29 PM's claim that a complete floor is being revamped and dedicated to UI!!! - regardless of the many problems to be fixed and scope of the MyHR system.

As for suggesting the ADHA is about to turn the health industry on its head !!! that simply suggests to me that you, or someone, does not understand the health industry. If you would enlighten us further I, and I am sure other readers, would be grateful.