Sunday, July 17, 2011

The New York Times Foray into EHR Usability

So the New York Times is throwing its hat into the Electronic Health Records (EHR) usability debate, mixing up terminology to reach a predetermined conclusion, as is customary in modern media coverage. The story starts with a blazing inferno in 1904 Baltimore and ends with a categorical statement from a highly credentialed source naming usability the “single greatest impediment to physician acceptance”. In between this skillful framing of the subject, there are the obligatory dissenting arguments from two EHR vendors and a bewildering array of expert arguments confusing usability with safety and interoperability standards, complete with the usual comparison of health care to aviation. 

The 1904 Baltimore fire, for example, where fire trucks from other cities were prevented from assisting the locals because their hoses could not connect to Baltimore’s water hydrants, makes an excellent argument for the need of interoperability standards in electronic medical records. It contributes nothing to support usability standards, since the problem was not traced to the color and softness, or ease of operation, of the non-Baltimore fire hoses. Nevertheless, most readers have no desire to perish in a blazing inferno induced by EHRs, so a receptive mindset is established upfront, whether it has anything to do with what follows, or not. The little jab at the vendors of fire hoses opposing standardization because they “did not want competition”, and so they “undermined the usefulness of, and investment in, the technology of the day”, is also helpful in framing the desired perception of what’s to follow.

The next nugget designed to create fear, uncertainty and doubt (FUD) is a statement from a computer scientist which obviously deserved its own two line paragraph: “This is an issue that potentially affects the health and safety of every American”. Yes, “changing the size, color and placement of graphic icons on a screen”, cited as an example of the deterministic and measurable science of usability, will definitely do wonders for the health and safety of every American. It will also contribute to gainful employment of many newly minted usability professionals, which is a good thing in these difficult economic times, and it shouldn’t raise the cost of producing EHRs by more than rich doctors can bear. And if government hires its own experts and then dictates where all the little icons should be placed, and what color they should be, maybe EHR vendors can actually cut costs by firing their own experts. After all, there is usually only one way to do things right, and when Bill Joy said that “innovation happens elsewhere”, he probably meant that it happens in federal government agencies and their contractors.

Let’s not forget that according to quoted “specialists”, usability standards worked well for “jet plane cockpits, air traffic control towers and nuclear power plant controls”, ergo “[s]ome of that expertise, …. , can surely be applied to doctors’ offices and hospitals”. Surely. Most Americans have little understanding of those complex industries and are both in awe of their potential disasters, and grateful for not being burned to a crisp by nuclear explosions and great balls of jet fuel fires on a daily basis. If all it takes is placing colorful little icons in certain spots on a computer screen, then by all means, let’s do it. Never mind the advances in avionics, composite materials, computer aided design and testing, and nuclear technology, the improved safety records must be all due to the novel placement of little icons. This is supported by a similar development in health care where marble floors and the presence of at least one atrium has significantly improved the quality of medical care as evidenced by a recent study that shows that critical access hospitals, that lack marble and atriums, provide inferior care. Probably because stepping on smooth Italian marble shaded by exotic banana trees, is much more satisfying for users, than walking on discolored linoleum with peeling edges flanked by cheap plastic ferns.

As to the categorical closing statement naming usability of EHRs as the “single greatest impediment to physician acceptance”, whatever acceptance means, I would suggest a quick literature review of physician surveys that constantly place the price of EHRs and the lack of calculable return on investment as the #1 impediment to technology adoption. Perhaps the experts interviewed or quoted in the New York Times are confusing usability with usefulness.

The government has a clear role in defining interoperability standards for EHRs and the FDA has a duty to ensure reasonable safety of software and devices used in medical care, but the placement and color of little icons has nothing to do with either and with all due respect to user experience experts, clinical safety should be left to those expert in that field. Forcing all EHR vendors to hire interior designers and to order Italian marble and live banana trees, because they seem reassuring, satisfying or just plain cool, will not increase the usefulness of EHRs. It will however drastically increase EHR prices, which are already on the rise as an unintended consequence of Meaningful Use. Once EHRs become truly useful to physicians, there will be no need to be concerned with the dubious “acceptance” factor.


  1. Margalit, you are in fine form today...

  2. Extrapolating from the physician survey abstract, solo or two physician practices don't adopt EHR because of price and obsolescence concerns...seems so logical.

    So a solution would be to seek joint purchasing arrangements or lower-cost solutions - both options seem to be in limited supply or lost in the EHR Superbowl marketing frenzy.

    Where do the free or nearly-free EHR solutions fit?

    Ad-sponsored: Practice Fusion, Mitochon Sytems

    Nearly free:
    Billing-subsidized: AthenaHealth, MedIT Resources

    Obsolescence concerns? Sounds like the flat screen vs my old tube TV discussion. I believe additional study would yield that the concern is about data back-up/redundancy & IT support


  3. Lehr, I do agree with your assessment.

    I may add that sometimes we compare apples and oranges when discussing price of technology. The practice management and billing price should be separated from the EHR cost discussion, since those are sunk costs - you just have to have them with or without EHR.

    The options you listed are valid, except that athena will charge you an additional percent of collections for just the EHR. Not very high and includes some very nice services like fax routing into charts.
    There are also other options to cut costs by using free claim clearinghouses, like Office Ally, which should be considered, again, with or without EHR.

    I think the obsolesce concern would be alleviated by ensuring robust standards for terminology and data exchange, and those are coming soon to an EHR near you....