Clinicians want electronic health records of the future to saddle them with less “cognitive burden” than those of today when trying to enter orders and grasp subtle changes in a patient’s condition, according to experts testifying on a Care Provider Perspective Panel at the HIT Policy Committee’s Adoption/Certification Workgroup hearing on EHR Usability.
“All too often, we hear from providers that they look forward to the day when the technology works for them, instead of them feeling like they work for the technology,” said newly minted National Coordinator for HIT Farzad Mostashari, M.D., in his opening remarks. “We hear from providers that they didn’t know what they were buying until they bought it, what it would be like to use, that there was not the transparency they hoped for. We hear about potential safety issues and about errors that can be attributed to the human/computer interface.”
After saying he hoped the meeting would generate guidance around metrics and measures that could be used to define usability, Mostashari said there was potential to go too far.
“There is a real risk that if this is done in a poorly thought-through way, if we take a too proscriptive approach, if the science isn’t there for how usability is to be measured or if we are too subjective, we could end up causing well-intentioned but severe unintended consequences,” he cautioned. “We could end up, in the extreme, mandating or regulating the design of software, and freeze in place the technology approaches of today. We could hinder the innovation that is so desperately needed, the disruptive and constructive innovation we need for tomorrow’s technology. That is our critical challenge.”
Mostashari further cautioned that he did not intend for the government to create a pass/fail testing system, whereby poorly scoring EMRs could not be marketed. “That is not the purpose of what we’re trying to do,” he added.
Christine Sinsky, M.D., a board certified internist who practices at Medical Associates Clinic and Health Plans in Dubuque, Iowa, testified she has seen deep discouragement among physicians with their EHRs because of usability issues, and added that improvements were “urgently needed.”
Sinsky, who speaks on practice redesign and the medical home, said EHR-associated administrative work had added two hours to the clinician workday. In addition, she said, many of the systems presented data in a “cluttered” way, leaving physicians struggling to identify meaningful information. This causes a “needle in a haystack” dynamic, she said, with “complex navigational pathways resulting in hard to see patterns.” Sinsky noted that just because a 15-page document has been imported into the electronic record, “doesn’t mean it’s easily available.”
As way to improve products that hit the market, she suggested usability become a component of EHR certification. Specifically, she said click and screen counts required to execute the same task on different vendor systems could give purchasers valuable points of comparison when shopping. “I’d like to see tests that showed the ability to make a cognitive decision,” she explained.
Sinsky went on to convey that physicians were bristling under federal mandates which seemed to heap ever more onto their already full plates. “It now seems a reflexive reaction to task physicians with all of this work, and that’s why they’re taking home two hours of documentation every night,” she said. “They feel disheartened and defeated by all of this extra work. They feel they’ve become secretaries and transcriptionists, and this has become unsustainable.”
Chantal Worzala, director of policy with the American Hospital Association, asked that EHRs not be looked at in a vacuum. She noted that, in hospitals, dozens of EHR and EHR-related applications are cobbled together to create a complete hospital information system. “This is also about how well the parts fit together, about the ease of integration,” she said.
Worzala noted that physicians weren’t the only ones interacting with EHRs, thus nurses, case managers, respiratory therapists and others also need to find the systems user friendly.
Nancy Staggers, PhD, R.N., a professor at the University of Maryland School of Nursing, testified that current EHRs caused “death by keystroke,” and were deficient in their ability to provide synthesized information for clinicians. She suggested creating a universal icon library that healthcare IT vendors could reference when creating their applications, thus facilitating usability for those jumping from one vendor product in their practice to another in the hospital, for example.
Other panels at the hearing focused on consumers, vendors, usability assessment, and usability improvement options.