Monday, October 29, 2012

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…..  


  1. The patient has the story, the patient needs to write it down, the doc might want to review it and categorize it, but the patient should write it down. Probably not just once during/before the visit, but an every day journal with what they're feeling, what medicine they take, what worries they have.

    Probably a lot of patients won't want/have time/can do it, but if some do, what a relief for doctors that could adapt to this style.

    1. Interesting idea... Some EMRs expose quite a bit of documentation on the Patient Portal (histories in particular and often ROS). Perhaps they should expose more....

  2. Very candid and insightful piece of work here. Walking in the other person's moccasins is a good way to understand his concerns, no?

    As I read I had two thoughts.
    First, when I have recently gone to a doctor I have observed three arrangements with inputting data. Once I saw a doctor doing it himself. But two or three times the busy work has been delegated to a PA with the doctor dropping in for a personal visit that was very short. He looked at what the PA had added to my file and pecked a little more himself, but the visit was soon over and we went on our separate ways. In a more recent visit with the eye specialist I was handled almost entirely by subordinates. They have a veritable hive of people doing everything from directing traffic to putting in eye drops. When the doctor appeared we exchanges a few sentences of small talk and he went immediately to work, mumbling some secret language in medical-code doctor-speak to the assistant who was pecking at the keyboard or screen (I couldn't see which). The assistant was cross-trained to be both understudy (I don' know what optical tech people are called) and secretary.

    These all seemed fairly straightforward EHR applications that sailed along pretty well. I think you were too hard on yourself when you got ambushed by that doctor who let you try to do his job. I once played the clarinet but if the principal clarinet player of the local symphony handed me his horn and said, "Here, you give it a try" I would have no desire to take him up on the offer. Heck, he may as well be handing it to the guy selling musical instruments at the retail music store.

    The second thought I had was this...
    I notice when I drive past hospitals I often drive for blocks, even a mile or two, and the place is surrounded in all directions by acres of offices, labs, imaging centers, specialty practices, pharmacies and other medical type businesses. Does anyone imagine they are all non-profits? Do the same people also believe in unicorns?

    I would like to see a comparison of the footprint in acres and number of ancillary businesses of some of the country's model ACOs (and yes, I know Mayo and others are not officially participating in the ACA experiments aimed at replicating their efficiency, effectiveness and lower per-patient cost) compared with the typical urban hospital campuses and surrounding medical-industrial complex. My guess is that the really good places will have a smaller footprint than those which have less impressive outcomes and/or higher per patient costs.

    I'm just guessing here, but I'm thinking that EHR works best when integrated with a collaborative system, partly because the interface is common, but even more because those places don't replicate the same records and information a zillion times when once or twice would be sufficient. I mean, how many times does one need to furnish one's name, address and insurance information to soldier through a network of places, all for one condition?

    I have a feeling that when and if real healthcare reform gets started there will be a lot of vacant real estate where vast campuses and out-parcels once were crowded. Ther may even be only two or three parking garages where now there are dozens.

    1. Hi John,
      That one doctor was a great friend and did me a huge favor by putting me through the wringer so to speak. It was probably one the most important lessons I learned in this profession, and as you probably can tell, it has colored everything I write as well.

      I am a strong believer in technology and I see electronic medical records as a natural evolution of the paper chart, which was invented at Mayo precisely to facilitate collaboration among treating physicians. I just wish they would let the product evolve based on what users really want, instead of having it serve a policy agenda and some greater good. This is not the right way to develop excellent technology (and I am all for the greater good in general).
      If the government wanted to kick start this, well, they did. Now it's time to step aside and let the baby find its own way.

    2. I totally agree. All new technology must evolve into greatness and not forced. Think back to when a new technology first emerged. The cell phone is vastly different now then it was 15 years ago. The internet; the days of waiting 30 minute for a page to load is long gone, and I am sure many people had discussions on how they wish the system was better. I could keep going but you get the point. The more people that start using these systems, the more feed back will be produced and slowly but surely EHR will evolve into something great. We just need to take the plunge into unfamiliar territory and give it time.

  3. Today I had a few eye tests. My optometrist decided to refer me to an ophthalmologist. After my exam, I sat in the chair for about fifteen minutes while he documented the tests, readings, etc. from my visit. I would have loved for an assistant there doing it, or better yet, if he would have handled it later. I would not have been able to add anything meaningful to the EHR.

  4. Great post, thanks for that.
    Maybe I missed it (owing to my not being native speaker of English perhaps?), but I guess it would be worthwile to point out explicitly that the main road block to adoption is the question of "getting the data in". All other functions, like CPOE, Image viewing, searching, scheduling etc. are - even they may be implemented badly in many systems - no PRINCIPAL obstacle. Getting the full content of a patients H&P into an electronic system, with sufficient detail and with the necessary formalization, is.
    This is not, and I know I'm going out on a limb here, the EMR vendors' fault. It is the lack of a generally applicable model of data gathering in clinical practice. There just is no descriptive and prescriptive formalization of what information to go for next. If it would exist, I guess there would be ways to make input by tablet efficient.
    What do you think?

    1. I think you are correct and the data collection as a whole is the problem, and the minimum data set (or information) that pertains to the actual patient-physician interaction is the most difficult problem to solve.
      The question in my mind is whether we should even bother with that particular piece (HPI or portions of assessment and plan) at this point, and maybe take an 80-20 approach and hold off on this until technology is ready.
      As you said above, there is plenty of data that is already auto-generated and/or can be captured by non-physicians, so maybe this should suffice.... for now... Just thinking out loud here....