Our health system has experienced an unprecedented change in the past decade. A mere 8 years ago in 2008, the Office of the National Coordinator for Health Information Technology (ONC) (2016) reported that less than 10% of non-federal hospitals had a basic EHR. After a lot of kicking and screaming a vast majority of health care providers have implemented EHR systems.
In 2015, according to the same report, 96% of acute facilities in the U.S. had ONC-certified EHRs. Small hospitals clocked in at an impressive 94% in 2016. For most providers, the incentives related to Meaningful Use were a driving force behind the EHR implementation. Although well intentioned and envisioned to promote better care, outcomes, and operational efficiency, use of the EHR remains a much debated and frequently divisive topic. Arguably, meaningful use drove the development of EHRs towards the prescribed rules, rather than a focus on end-users and their need to enhance their daily workflows.
The current view on EHRs
Despite legislative incentives, regulatory and quality drivers to support this transformation, everyone is not happy and all is not well. Providers, clinicians, and executives are reticent to declare EHR adoption as a victory won. When EHR implementations are difficult or fail, clinicians frequently attribute this to an inadequate voice in the development process. That voice speaks to the complexity of technology-infused workflows and the need to understand and streamline steps/tasks of clinical processes. Much of the end-user clinical community today perceives itself to be working for the EHRs, and not the other way around.
One can argue that progress made over the last decade in EHR adoption has opened up new horizons in population management and big data analytics, and introduced us to concepts such as computer-guided clinical workflows, implementation of best practices, and clinical decision support. However, the progress continues to be overshadowed by user dissatisfaction. It is no surprise that 25% of providers are looking to replace their current EHR systems, citing sloppy user-interface, rigidity in design configuration, and burdensome workflows.
Addressing user dissatisfaction and the Amazon model
Why have some companies like Amazon have figured it out and healthcare still continues to limp along? When was the last time you needed a 30-minute in-service just to learn how to navigate through Amazon? Don’t say you were not impressed with the concept of Amazon’s one-click ordering either. Simplicity, customization, efficiency, and clean design are all cornerstones of user-friendly design—and sadly lacking in many of the major EHRs that are currently in use.
The good news is that the health care industry is waking up and providers are demanding better usability, but the bad news is that health care IT capital budget spend levels are among the lowest when compared to other industries such as manufacturing or retail. So, how can a positive user experience be created on a tight budget?
First, those designing EHRs have to consider who the intended users are and how they move around during the day. It is important not only to understand the workflow but also the “life flow” of the clinicians for the development of a well-adopted EHR system. One of the key elements in methodology is to solicit end-user feedback by engaging the user in early stages of development and design. Not being IT professionals, clinicians are not always adept at describing what their needs are. That’s why the design and development of EMR applications needs to be guided by iterative prototyping, and getting the prototypes in front of target clinicians for real-time feedback.
Clinicians don’t have elephant-like memories. They won’t remember each patient encounter and be able document with complete accuracy when they finally sit down at the designated desktop. So if the intended target users are nurses moving between patient rooms, the EHR system will need to move right along with them in a tablet or laptop form. If EHR users also include physicians traveling between office, clinics, and hospitals, then an investment will need to be made in mobility platforms. And then there’s integration. Seamless integration will not only make end-users happy, it will also positively impact patient outcomes and care coordination, and reduce waste from the system. Not to mention the company data analysts will jump for joy.
Lastly, a simple and clean design that clinicians like can really differentiate an EHR. Replicating an eye-pleasing and easy-to-learn-and-adopt design across platforms and devices for consistency and uniformity creates a seamless and satisfying user experience.
Good health IT
Scot Silverstein at Drexel University defines good health IT as “the IT that provides a good user experience, enhances cognitive function, puts essential information as effortlessly as possible into physician’s hand. It is also easily substantiated and cost-effectively customized to the needs of the medical specialties and subspecialists.”
No one forces the shoppers to use Amazon by threatening to revoke their shopping privileges or similar punitive actions; the shoppers flock to the site because it is efficient, effortless, and hassle-free. So, instead of thinking about how to strong-arm physicians/clinicians by use of various penalties, to give up the pen and use electronic systems, we should work hard in concert with the clinicians to create efficient, clever, and attractive EHR systems that entice users by adding value to their “life flows” and technology, being an enabler instead of a disruptor.
Ahmad Sharif, MD, MPH, is Vice President of Clinical Health Information Technology at Fresenius Medical Care. Dr. Sharif has extensive experience in health information technology, consulting with over 25 health systems across the country and abroad, implementing and optimizing electronic health records, clinical practice management and technology solutions for multi-facility large academic institutions and smaller community and critical access hospitals. He is currently working on projects to improve clinician satisfaction and adoption of clinical information technology.