The EHR Non-User Interface

Every time someone publishes an article or a paper or a blog post that has anything remotely to do with Electronic Health Records (EHR), there is usually a flurry of reactions in the comments section, now available in most publications, and these always include at least half a dozen anonymous statements, usually from clinicians, decrying the current state of EHR software, best summed up by a commenter on THCB: “It is the user interface stupid!... It has to be designed from the ground up to be an integral part of the patient care experience”. Can’t argue with that now, can you? Particularly when coming from a practicing physician.

And why argue at all? The user interface in any software product is the easiest thing to get right. All you need to do is apply some basic principles and tweak them based on talking to users, listening and observing them in their “natural habitat”. Having done exactly that, for an inordinate amount of time, and being aware that most EHR vendors were engaging in similar efforts, I found the growing discontent with EHR user interfaces somewhat inexplicable.  The common wisdom in EHR vendor circles is that doctors are unique in how they work and whenever you have two doctors in a room, there are at least three different preferences in how the EHR should present itself. As a result, you will find that most mature EHRs have dozens of different ways of accomplishing the same thing. These are called “user preferences” and are as confusing as anything you’ve ever seen. Hence the notion that if you spend enough time configuring and customizing your EHR upfront, you will increase your chances of having a less traumatic EHR experience down the road. We were an industry like no other, doomed to build software for users with no common denominator, or so I came to believe, until one afternoon in the summer of 2006…..

My personal moment of Zen occurred in an unremarkable little primary care practice somewhere in the Pacific Northwest, where a kind and wise physician offered me a chance to play doctor, right there in his cramped exam room. He handed me his shiny new tablet and sat in the patient chair across from my rolling stool. I saw that as the perfect opportunity to teach the doctor how to use “my” software. I designed large portions of it and I’ve done hundreds of “live” demos of patients with diabetes, hypertension, COPD and “by the way” to showcase the ease of use and uncanny abilities of the EHR to simplify the most onerous tasks. And then he started talking. A simple visit. A little bit of gout. Some stiffness when climbing stairs and he didn’t like his new blood pressure meds. I couldn’t keep up. I couldn’t find the right templates fast enough. I couldn’t find the right boxes to click on. I tried typing in the “versatile” text box. I am a lousy typist. I tried to write stuff down with the stylus in the “strategically located” handwriting recognition box. I kept making mistakes and couldn’t erase anything. I tried to type code words for completing the note later. My head was down and I was nervously fumbling with the stylus and the tablet keyboard and my rolling stool kept moving unexpectedly. I would have killed for a pencil and a piece of paper. I finally looked up in total defeat and saw the good doctor’s kind smile, “now you get it”. Indeed.

A recent Tech Crunch article is quoting Prof. Christensen’s (of Innovation fame) assertion that “Understanding the customer is the wrong thing to do — it’s confusing”. It seems that Prof. Christensen believes that “what’s really important is understanding the job that customers are trying to accomplish, and only once an entrepreneur truly understands the need that a product or service fulfills for the buyer can they optimize their business or product”. I couldn’t agree more. So what is the job that EHR customers are trying to accomplish? What need does the EHR fulfill for the buyer? Are the job and the need one and the same? They are not, and the difficulty in creating an interface that satisfies EHR users arises because doctors love the job and hate the need. The job is to heal people and the need is to be properly paid for services rendered, including an escalating system of regulatory incentives and penalties for activities not immediately related to patient care.

Most physicians would describe their job to be the provision of medical advice to patients seeking their help and, to paraphrase Sir William Osler, most doctors will probably agree that observing and understanding the patient who has the disease is much more important than understanding the disease itself. So what can a contemporary software program contribute to observing and understanding patients? Nothing of any significance. Someday we will have intelligent software accessing sensors plastered on patients’ organs and clothing and perhaps then software will be able to assist with observation and understanding. But right now software can only offer protocols for simple and self-evident conditions. If the original electronic calculators were only able to multiply single digit numbers, nobody would have bought anything from Texas Instruments in those early days.  How about the other parts of a physician’s job? Can EHR software help with delivering babies? Or performing surgery? Or at the very least, can it assist with a physical examination? Maybe an EHR can help with formulating treatment plans and ordering therapies? Mostly an EHR cannot do any of these things, and the little it can do comes at great inconvenience to physicians, when compared to methodologies it aims to replace.

But doctors are buying EHRs at increasing rates, so perhaps EHRs cannot help with the job itself, but they fulfill a need after all. The original need EHRs were designed to fulfill was the simple need for one to be paid for the job one was doing. This is the same universal need that drives every business to acquire and use accounting software. Generating proper invoices for services rendered (claims) was the first rationale for buying software in a medical establishment. As the rules and regulations for payments became more and more complex, the need for software increased and in parallel the software began interfering with the job. And although most physicians realized that they must allow the software to interfere if they wanted to get paid properly, it didn’t require that they like this interference. Most of us pay our taxes, but this does not stop any of us from complaining about the complexity and lack of user friendliness of the tax code. Later on, Meaningful Use and other “quality” reporting initiatives introduced regulations directly into the job of physicians and their staff. EHR software, still unable to contribute much to the job, is now fulfilling a much larger and more onerous compliance need, and at least from a physician perspective, it still has to do with being paid appropriately for services rendered.

Designing an EHR from the ground up to be an integral part of the patient care experience, as the anonymous commenting physician suggested, was never in the cards. EHR software was born to fulfill externally imposed needs, and as such it was destined to be regarded with suspicion and when those needs started invading every aspect of the job, even early supporters of computerization became disenchanted with EHRs. It doesn’t really matter how many user centered usability experts the government regulates that EHR vendors employ, because it’s not about the buttons and the clicks, it’s about what the buttons do. At a recent conference I saw a presentation delivered by two primary care doctors who found a way to restore happiness to the practice of medicine. Every slide had a picture of an exam room where in addition to a happy doctor holding the hand of a sweet patient, there was a third “team member” in the background fumbling with a tablet.

Shouldn’t there be a better way? At one point shortly before the advent of Meaningful Use, there was a slight buzz in the industry regarding something called EMR Lite. A brand new notion of creating software humble enough to take on the peripheral portions of the job that could be automated with existing technology. That seed of innovation was killed off by the perpetual onslaught of Meaningful Use requirements. Should it be revived? And if so, what should it look like? Stay tuned…..  

Remembrance of Docs Past

It was 10 AM and the unmarked glass door was locked. A woman in a brightly colored dress with a big smile on her face waved from inside, disappeared for a brief moment and returned with a key, unlocked the door and welcomed us to Dr. Elliott’s brand new solo practice. The small rooms were brightly lit, sparsely furnished and smelled of fresh paint. There were two elderly patients in the waiting room and one empty chair. In the next room there was a desk with a big monitor, a new printer and lots of framed pictures of happy people holding little children in their arms. Unpacked boxes and crates were stacked up in one corner and across from it the exam room door was closed. Dr. Elliott was with a patient. Mrs. Elliott, the lady with the brightly colored dress, produced a couple of extra chairs from thin air and told us all about the happy people and the little children in the framed photos, while answering phones, making appointments, checking authorizations, printing all sorts of papers, preparing charts and arranging for referrals, all at once. It was 10:30 AM and the exam room door was still closed. I was beginning to understand why Dr. Elliott’s finances were less than stellar. The door finally opened a few minutes later and a tall and gaunt gentleman with a thin colorless ponytail sticking out the back of his green baseball cap walked out of the exam room holding some papers in his hands. Dr. Elliott walked right behind him finishing an unfinished conversation with his patient and starting a brand new one with us. The patient decided to hang around and participate and somehow this looked and felt just right.

Dr. Elliott is a bubbly fidgety man in his mid-forties, and this little practice was his desperately brave response to rejection after rejection from organized medicine. Dr. Elliott was either invited to leave, or quit on his own, several health systems due to his inability to meet productivity quotas. Somehow I was not surprised, and the patient with the thinning ponytail had a toothless grin on his face. Turns out Doc wants to know everything, even what he had for breakfast today and maybe Doc should pay him for doing most of the talking. He slowly pulled a $10 bill from his stiff jeans pocket and handed it to Mrs. Elliott who thanked him and handed him a receipt which he stuffed back in the same pocket, shook hands with everybody in the room and left escorted by Mrs. Elliott who unlocked the door for him and locked it behind him. I just had to ask…

“I take insurance, but if they don’t have insurance, they still need a doctor, so they pay what they can”. My partner mumbled something about chickens. Dr. Elliott walked back into the exam room and closed the door behind him. Mrs. Elliott, still doing five things at once, told us about the new EMR they just bought and how they are working on becoming a medical home, and maybe soon she’ll be able to get a good phone system so she doesn’t have to forward calls to her personal cell phone. There was someone knocking at the door. Two teenage girls came in and one wasn’t feeling well. Can she see the doctor? Sure. The girl who wasn’t feeling well had no insurance either. Another half hour went by and Dr. Elliott walked out from the exam room behind a perky little old lady with huge glasses and cropped white hair. Miss. Sally also decided to stay and chat with us for a bit.

Miss. Sally was suffering from congestive heart failure and was in and out of hospitals for most of last year. She was pretty sure her time has come until she found Dr. Elliott, and he found a cardiologist for Miss. Sally and together they worked things out for her. She is as good as new, or so she tells us. No more hospitals for her. Instead she visits with Doc once a month and sometimes he sends her to see the cardiologist. Miss. Sally was having a grand time being the center of attention. Doc saved her life.

The teenage girl who wasn’t feeling well looked up from her cell phone for a brief moment and agreed to wait a few more minutes so Dr. Elliott can complete his oration on evidence based medicine, the importance of primary care and his great expectations from his soon to be installed state of the art EMR system. He gave Miss. Sally some education materials she will never read, and walked us to the locked door. This time I didn’t have to ask. There were some “incidents” close by and “once they walk through that door, they are my patients, and I am responsible for their safety”, said Dr. Elliott as he unlocked the glass door. As we said our goodbyes I caught a glimpse of the office hours painted on the glass in a soft gray font. The last line read Saturday 9 am – 7 pm.

The rain stopped and a hot Alabama sun was baking the dusty row of little storefronts. A distraught woman walked by looking for a bathroom. We drove back to the city passing by a cinderblock hospital with fat pipes sticking out in every direction, and I wondered how many little old ladies with congestive heart failure are in the process of dying there now. It was getting dark outside.

Note: In order to protect their privacy, the names of all people mentioned in this post have been changed, as have certain physical characteristics, quotations and other descriptive details.

The Market for Patient Engagement

Wherever health care reformation and transformation is discussed, sooner or later the imperative of patient engagement is sure to materialize. Patients, it seems, are no longer content to be passive spectators while care is administered to them, and instead are demanding to be active participants in their own health care decisions. Gone are the paternalistic days of doctor knows best, replaced by informed and educated patients on an equal footing with physicians when it comes to diagnosing conditions, selecting therapies and managing illness, or preventing disease altogether through judiciously chosen lifestyles and preventive measures. And what makes this tectonic shift in attitude possible? Technology, of course, and specifically the Internet and the iPhone. Patients today have access to troves of medical information on the Internet, and social media allows for informal research on any condition you can think of, and some you cannot even imagine. The iPhone, turned medical instrument with the assistance of thousands of apps and add-on devices, is allowing everybody to carefully track and monitor their lifestyles, biometrics, medications and whatever else they wish to quantify. iPhones are already providing some diagnostic testing and it’s probably not too soon for Quest and LabCorp to start paying attention to these engaging developments.

The Government is also very interested in promoting patient engagement, since engaged patients who can monitor and maintain healthy lifestyles, and if already sick can self-manage their chronic conditions, will presumably utilize less medical resources and should cost the system less than their apathetic predecessors. And for similar reasons, private insurers and employers are fully supportive of patient engagement as well, and are diligently working to provide patients with educational tools and resources for engaging in their own care within the cost optimizing care management universe. Patient engagement is also one of the pillars of Meaningful Use and as such it is creating the necessary infrastructure and associated regulations to ensure that patients have meaningful access to all medical records previously locked up in providers’ information vaults. This is extremely important because patients cannot truly engage in lifestyle improvements and self-care on a level playing field with their physicians without complete knowledge of their medical conditions as documented by a physician, and as augmented, translated and analyzed by iPhone apps and the Internet at large.

Earlier this year Chef Mario Batali, an extremely engaged and empowered individual, decided to engage himself and his family in an innovative lifestyle change experiment of his own. For a full week, seven days, Chef Batali and his family went on a SNAP diet. The Supplemental Nutrition Assistance Program (SNAP), a.k.a. Food Stamps, diet consists of eating whatever you can buy for $31 a week. Of course, being handy around the kitchen, gave Chef Batali a bit of an advantage, but all in all, according to the Huffington Post, his description of the experiment was "I'm (expletive deleted) starving".

There are 46.2 million Americans living in poverty today. Poverty is currently defined as less than $23,021 per year for a family of four. There are 47 million people in the SNAP. 22% of American children live in poverty and in our Nation’s Capital, next door to Congress and the White House, 35% of children are poor. According to the USDA, 17.9 million households were food-insecure in 2011 and 6.8 million of those had very low food security, which translates to 49 million Americans who don’t know where their next meal is coming from, or if it’s coming at all, and 16 million of those Americans are children. A fairly new study from the University of Michigan and Harvard concludes that at the start of 2011, “2.8 million children were surviving on $2 or less in income per person per day in a given month”. And NCFH reports that in 2010, 1.6 million American children were without a home.

What does this have to do with patient engagement? Well, for starters when you are “(expletive deleted) starving”, it is a bit more difficult to muster the mental prowess required to engage your health care provider on a level playing field. The landmark “quasi-experimental” study on inviting patients at several elite health care institutions to view their visit notes, published earlier this month, did not measure the level of hunger amongst participating patients and/or their children. So, if you are building patient engagement paraphernalia and expect to be paid for your efforts, your target market excludes the 49 million food-insecure Americans and in all likelihood excludes most of the remaining 50% of Americans living on less than the $50,054 median income, and probably the vast majority of the more fortunate 50%, some of whom may be able to afford your products if they were chronically ill or actively preparing themselves for medical disaster, which most are not. This is probably why patient engagement is something thrust upon the health care scene from above, just like EHRs, and not a market demand sprouting from unfulfilled needs of would be buyers. And this is also why, patient engagement campaigns, just like EHR adoption efforts, are financed by the middle-men of health care (i.e. those who use our collective health care dollars to purchase medical services on our behalf), in the belief that somehow patient engagement fueled by technology will reduce the costs of medical services. These “purchasers” of health care services are the most likely target market for patient engagement tool builders, service providers and the quintessential consultants.

This is not an entirely bad idea, just like covering a gaping wound with a Band-Aid is not an entirely bad idea, and there is plenty quasi-experimental and quasi-scientific research to show mild correlation between costs and technology, and it doesn’t take a genius to figure out that if patients managed their own care, and if they did it well enough, we would need to pay less to medical professionals for doing the same. The new iPhone and Internet based care management products are certainly promising to dramatically improve lay patients’ abilities to take care of themselves. The mountains of patient education tools and materials written at a “culturally appropriate” 4th grade literacy level with lots of colorful pictures and big fonts are presumably targeting, amongst others, those who are on and off “(expletive deleted) starving”, and may even help avoid a trip to the ED for some asthmatic children surviving on $2 a day. But this type of palliative approach to poverty is not likely to have significant impact on costs of care, because instead of shrinking away and perishing, poverty seems to grow and expand by leaps and bounds, and since 1/5 of our future generation is infected, the growth of expenditures well into the foreseeable future is pretty much guaranteed. Why? Because poor people are disproportionately sicker than rich ones (see CDC numbers below), and no amount of colorful pamphlets and free apps is going to change that.

If you are one of the many talented and passionate people working diligently to improve health and health care in this country, you may want to quit the Band-Aid public-private industrial complex that is squandering billions of taxpayers’ dollars in a futile attempt to provide cheaper care to poor people, and perhaps consider redirecting your efforts towards solving the underlying problem of poverty, and reducing to zero the number of Americans, particularly children, who are “(expletive deleted) starving”.

The Big Birds of Health Care

For the first time in this election campaign Mitt Romney came up with a useful “zinger”. During the first Presidential debate Romney suggested that we should examine our various expenditures and ascertain if the item we spend taxpayers money on is “important enough to borrow money from China”. Unsurprisingly, the first thing that came to Romney’s mind was a public service providing small children with education on racial diversity and basic literacy skills. And although, we are not directly borrowing money from China to pay for things, it wouldn’t hurt to go through our expenses, including the many small and apparently insignificant ones, and see if there’s anything we can do without. It actually may be less painful to make a thousand additive little cuts than to locate one large silver bullet that is certain to cause commensurately large pain. Of course, such exercise would be fraught with controversy, since what may look frivolous to one party, could look worthwhile to another. But if we approach this with an honest intent to generate some savings, would there be some Big Birds that we could all agree to do without for now?

A day after the Presidential debate the Republican Chairs of the Ways and Means and Energy and Commerce Committees published a letter addressed to the Secretary of Health and Human Services asking that Meaningful Use payments and penalties be suspended, and the program be reevaluated because it failed to reach its stated goals of having EHRs “talk to each other”. As political and misguided as this letter is, perhaps there is an opportunity here nevertheless to go looking for Birds. The Meaningful Use program is costing taxpayers around $35 billion, and it has been said that this is just a drop in the bottomless bucket of public health care expenditures, but Meaningful Use has other costs associated with it. Technology vendors subject to these new regulations are spending money to make their products compliant, or certifiable, which is increasing the price provider organizations pay for technology, which is then increasing the prices health care purchasers are charged. These new regulatory activities, consisting mainly of data collection, aggregation and reporting, are imposing additional operational costs on providers, which are then also passed down to purchasers, and since nobody is running a charity in health care these days, all these costs are trickling down to taxpayers in various ways.

The original idea behind Meaningful Use was that EHRs will eventually pay for themselves in the form of enterprise efficiency that will reduce costs and improve quality of care simultaneously. So far it looks like enterprise efficiency is translating mostly into higher revenues for providers and higher costs for health care purchasers, and as far as quality is concerned, the jury is still out. So should we ditch Meaningful Use because it does not pass the Romney litmus test for keeping Big Birds alive? Not necessarily. Meaningful Use is not a monolithic program than can, or should, be evaluated in one swoop. Some parts of Meaningful Use look reasonably fit for purpose while others look more like clusters of big yellow feathers randomly slammed onto the main regulatory body, and perhaps those should be removed.

Let’s start with the basic assumption that complete medical records, when made available to clinicians and patients at the point of care, can indeed improve the quality of care for individual patients, and when used for outreach and research, can improve population health and reduce costs. This same assumption, made by Dr. Henry Stanley Plummer in 1907, prompted the revolutionary transition from physician ledgers to today’s patient chart, so this should be a pretty reasonable assumption to make. If that’s the case, does Meaningful Use have any unessential feathers that we can safely remove and thus lower the costs of this program without hurting its main intent?

Yellow Feathers Cluster #1: Both the architects of Meaningful Use and the authors of the letter asking for the program to be suspended, assume that figuring a path through the deep weeds of futuristic technology is a prerequisite to providing physicians with useful information at the point of care. So the regulators deemed it appropriate to require that 50% of discharge summaries, for example, should be produced in a specific format while 10% should be sent out using the latest standards and technologies. What about the remaining 90% of patients? And how do you decide who the lucky 10% should be? If we put aside the technology centric approach to solving problems, we could require that 100% of discharge summaries are sent out to primary care doctors, nursing homes, patients and other care givers, by any means and in any form or shape available. So maybe EHRs can’t really “talk to each other”, but they can make it possible for doctors and patients to “talk to each other” more efficiently. Would any hospital stand up and argue that generating and sending discharge summaries by secure email, electronic fax, plain fax, FedEx, carrier pigeon or whatever, is a hardship? I don’t think so, and if they did, they would probably pressure their technology vendors to automate the process.

Yellow Feathers Cluster #2: Meaningful Use was supposed to have 3 stages: data collection, information exchange, quality improvement. Since Stage 4 is already in discussions, I would assume that Meaningful Use is envisioned to have transformed from a temporary tool to spur technology adoption to a perpetual mechanism for enforcing policy through technology. Either way, the starting point was presumptuous, ineffective and wasteful. Clinicians in all settings were already documenting what they thought was necessary to document in the patient chart. Before endeavoring to let information be exchanged, the Meaningful Use architects decided to enforce their vision of what should be documented and subsequently exchanged. Thus we now have smoking status on every piece of paper, along with race and ethnicity, and in Stages 3 & 4 we will have disability status, sexual orientation and gender identity in the header of every clinical summary, and armies of disenchanted doctors and nurses clicking away at boxes. What would happen, if instead of defining the fields required in “clinical summaries”, we would ask that 100% of referrals (and consults) be accompanied by at least the last visit note, a referral letter and the last test results, if any? Again, by any means available and in any format the referring (consulting) physician can produce.

Yellow Feathers Cluster #3: Other than complex attempts at new venues for information exchange, Meaningful Use is chock full of a veritable smorgasbord of little features and functionalities, which may be nice to have if money was no object, and doctors’ time was unlimited, and others that are ridiculously self-evident, such as creating visit notes and recording family history (seriously?). Should we “borrow money from China” to ensure that every doctor stares at the insurance company formulary for a few seconds before he prescribes Amoxicillin? How many dollars should we take out of the ailing Medicare trust fund in order to pay hospitals and doctors for sending a “failed message” to an immunization registry?  How many kids should we kick out of Medicaid so that the militant app developers can dupe patients into “transmitting” their medical records to their marketing machines on the physician’s dime and infrastructure? It’s easy to come up with ever increasing complexity when there are no real constraints. It’s called scope creep and it’s been the death blow of many good projects, even for those who don’t need to “borrow money from China”.  How about picking two or three realistic things that will give us the biggest bang for the (limited) buck and just concentrate on doing those really well, so we can build from there?

Yellow Feathers Cluster #4: This last cluster is impossible to completely remove. The Meaningful Use incentives structure is just plain unfair and exceedingly wasteful, although more than likely intended to be so as a means to a policy end. There are no published numbers from CMS or ONC indicating the number of incentives recipients that bought and implemented an EHR long before Meaningful Use was created. Most of those “early adopters” were big systems like Kaiser and financially comfortable medical groups. Even if we accept the assumption that Meaningful Use of an EHR can improve quality of care, why would we borrow money from China to pay businesses for investing in their own bottom lines of their own accord? Whenever I ask why it is that Kaiser’s premiums are not much lower than its less “effective” competition, I am reminded that Kaiser must recoup its billions in technology investments. By my back of the napkin calculations, they should have recouped that already, so why should taxpayers deplete their old age medical funds to throw a few hundred millions more in Kaiser’s way? If we really want to improve quality of care, shouldn’t we concentrate on bringing up the rear, and shower Critical Access Hospitals, Rural Health Clinics and small practices everywhere with technology funds? Every study out there shows that these small providers are struggling financially and technically. Meaningful Use incentives should have gone exclusively to these small and needy establishments, most of which are serving equally impoverished patients, instead of padding the pockets of large systems so they can more easily buy these small providers and create the currently preferred “too big to fail” model of health care delivery.

I’m sure you can think of more feathers and clusters, and Meaningful Use is just one health care program that lends itself to productive plucking. Shall we begin applying the Romney China Test to all other sacred Big Birds in health care and start adding up the billion dollar drops in the bucket? Or will that make us look dumber than we would like to look?