Usability is the Key

Jack Callahan, EVP at SRSsoft, continues the drumbeat for usable electronic health records in an opinion piece on ModernHealthcare.com (registration required):

The high EHR failure rate is largely attributable to the fact that either they are just too hard to use for many physicians, or slow them down too much.... While the hard-dollar cost of an EHR is certainly a concern to many physicians and practices, that problem would not even be solved by providing these traditional EHR products free of initial costs to each of them. "Usability" is an essential missing ingredient in the CCHIT formula.

Traditional EHRs -- and there are a bewildering array of them in the market -- come with a host of other issues that have created resistance and inertia during the past 10 years or so of deployment: failed installations, long learning curves, high cost of training, lost productivity because of seeing fewer patients, anathema toward using electronic charting in the presence of the patient, difficulty in doing any "new" tasks with the system, poor integration with other essential systems, nonintuitive user interfaces with nested menus, pull-downs and pick lists. These are a few EHR problems the market has struggled mightily with. Adding financial incentives does little to solve these at all.

The process of “certifying” EHR products can help greatly in lifting these nonfinancial obstacles, but only if “usability” becomes an essential element of the certification process. The de facto certification criteria are presumed to be CCHIT’s list of 480 functions, regardless of how they are accomplished....

With CCHIT's 480 functional requirements in place, and more coming in 2009, EHRs are being driven to largely identical functionality. The only way to differentiate between the vast array of EHR products is to have a "usability" standard defined for performing key functions....

[emphasis added]

Whether we buy or build, whether or not CCHIT (the Certification Commission for Healthcare Information Technology) adds usability criteria to its certification process, CCHS must make usability a central requirement in all software acquisition decisions if we are to truly leverage the promise of technology.

More on EMR

Alan Bingham, Senior Marketing Manager at AliMed in Dedham MA, offers some additional observations about EMRs on ModernHealthcare.com (registration required):

"Doctors should hate the current raft of electronic medical records. They are generally unhelpful and do not provide the benefit they should. The basis of the problem is that the information technology vendors all have their own ideas that fit within their technology limitations and can’t see beyond this. Pair this with the failure of interoperability and you get something that is not workable in reality. Without the complete information from all medical sources, how can a physician review priority variables?

Omissions because of lack of interoperability are key. Because the practice of medicine is an idiosyncratic art form, the "perfect" disease without co-morbidities is a fallacy, and yet most EMRs are based on the concept of the perfect example, in isolation. And information is stored variably, from tabular numeric pathology results to staging protocols to text notes. How do we bring together the essential information, in its necessary format to enable a pre-encounter review, understand status and the nature of the problems—not necessarily the diagnosis—and what we are doing to treat them is vital.

Because the vendors have not cracked this nut and because they are too busy trying to sell what they have instead of solving the problem, we have products that are clumsy, require too much time and effort, and don’t deliver on results.

There are answers. The technology exists, but we need someone to bring it together and make it professionally useful. And, yes, doctors are smart people. That’s why they don’t want to use something that doesn’t deliver the outcome.

(emphasis added)

The "build or buy" question is always with us. Given Mr. Bingham's analysis, it sounds like there is still room for an optimal solution to emerge, but I would not yet leap to the conclusion that we can or should build it ourselves. I think we should start by assigning a cross-functional team to evaluate the existing products in the marketplace -- now!

Are we ready for Twitter in the OR?

Before you recoil in horror, check out this story on CNN and consider possible benefits (as a teaching tool, a consulting mechanism, a family involvement mechanism...).

I'd be interested in your thoughts!

For those unfamiliar with Twitter, here's a description.

Human Factors in the EMR

Anne Armstrong-Coben, an assistant clinical professor of pediatrics at Columbia, has an op-ed in today's New York Times in which she worries about the downside of electronic medical records (EMRs):

Doctors in every specialty struggle daily to figure out a way to keep the computer from interfering with what should be going on in the exam room — making that crucial connection between doctor and patient. I find myself apologizing often, as I stare at a series of questions and boxes to be clicked on the screen and try to adapt them to the patient sitting before me. I am forced to bring up questions in the order they appear, to ask the parents of a laughing 2-year-old if she is “in pain,” and to restrain my potty mouth when the computer malfunctions or the screen locks up. I advise teenagers to limit computer time as I sit before one myself for hours each day until my own eyes twitch and my neck starts to spasm.

In short, the computer depersonalizes medicine. It ignores nuances that we do not measure but clearly influence care.

As we begin to formulate our strategy for effectively implementing an EMR system at CCHS, we must pay as much attention to the usability of the software -- the human factors that will utltimately determine its success or failure -- as we do to the medical and technical requirements.

Security is EVERYONE's Business

In the "be careful what you ask for" department, IS Assistant Director Noel Rasmussen alerts us to a story on nextgov.com, a website devoted to the technology and business of government, which reveals how filesharing networks, such as those used to access "free" music on other users' hard drives, have compromised tens of thousands of medical records.

This is a dramatic (and, in Noel's words "scary") illustration of the risks posed by allowing any medical information to leave our protected network. These medical records were not accessed through breaches in network security, but were obtained from external computers where the sensitive information was (hopefully) legitimately stored. But the compromised computers contained "peer-to-peer" filesharing software, typically downloaded for free for the purpose of sharing media files. Unfortunately, these applications often expose all files on the user's computer, putting any sensitive data on the computer at risk.

Since we are all individually (as well as collectively) responsible for the protection of health information that is entrusted to us, all HSD employees should be aware of these risks and use due diligence in protecting any PHI that may be stored on home computers. Please do not keep any work-related data on computers that have peer-to-peer file-sharing software!