Sunday, April 19, 2009

Improving EMRs: Usability, Usability, Usability

I've been working on physician adoption of EMRs my whole career, sticking to the mantra that "there are no benefits without use". And I've been fortunate in the past few months to be able to focus some extra time on this topic as part of a project on "The Future EMR" sponsored by the Szollosi Healthcare Innovation Program (

I think this topic of Physician Adoption of EMRs is particularly relevent due to the recent Health Information Technology for Economic and Clinical Health Act (HITECH) bill for funding "meaningful use" of EMRs in an environment which has not yet seen much adoption, as evidenced by a Fall, 2008 NEJM article which found just 4% of US doctors using a "fully functional" EMR in the outpatient environment, and only 15% using a "basic one" (NEJM, July, 2008: Electronic Health Records in Ambulatory Care — A National Survey of Physicians).

So while adoption has many mothers, I'm going to suggest we are wise to focus on the "Three I's" to understand how to improve adoption:

(1) Interoperability: What a bugaboo. While many say that we don't have enough, I'd actually argue that we are so obsessed with this issue that we are losing the forest for the trees. In other words, let's get doctors using systems first, and worry about interoperability later. I realize that is a bit heretical, but the truth is that the majority of healthcare is local - and what we really care about is making sure that our EMR interfaces with our local PM system, lab, Xray facility, etc... rather than worrying about some regional or national sharing. The latter is still important, and there are always great anectdotes about having access to an ECG when on vacation, but let's start shifting some of the interoperability obsession to usability obsession (which I understand CCHIT is doing - and I approve!). Meanwhile - tell your patients (at least the sick ones) to keep a piece of paper in their wallet with: allergies, meds, problems, the names of their doctors and perhaps a copy of their ECG. I guarantee that one of the first thing paramedics do is go through someone's wallet or purse to look for this type of info.

(2) Incentives: No surprises here - we all know a system gets what it is designed to get, and right now, our healthcare system reimburses based on volume over value, and quantity over quality... and the former is pretty much what it gets. So clearly we need to create a reimbursement system that rewards physicians for value and quality... and if they achieve these things, they should get those rewards whether they use EMRs or not (but I suspect it will be easier to do this with EMRs than without). I think the HITECH bill is a positive step and truly a "stimulus", but we still need to figure out how to improve long term, day to day reimbursement to make sure doctors are rewarded for doing the right thing.

(3) Interface ("User interface" or "Usability"): This third point has always held great interest for me, since I have often had to use the systems I build. So I feel the pain when it takes 25 clicks to refill a med because EMR vendors still don't seem to understand that for me to refill a med, there is a ton of contextual data needed. For example, I need to know: what I was thinking at the last appointment (e.g. did I tell the patient to return in 3 months, and it has now been 5 months without a return), do they have an upcoming appointment, did the labs from the last visit alter my thinking on their follow-up, or has anything happened in the interval. In a typical EMR, I need to click all over the place to find this information - how come it can't just bring it all to me (answer- technically it is possible, but the EMR vendors just don't seem to get it).

This idea that the EMR needs to pull together and present "what we need to know and what we can do" is a recurring theme in my diatribe on Usability - the screen shots for specific workflows (e.g. med refill, lab review, phone message, office visit) should consolidate all the information I would likely need to review to complete that workflow (e.g. meds, labs, visit dates, notes) - ideally in a manner that is easy and quick to read: "Data visualization" may include graphics or other data manipulation (e.g. calculate the anion gap, or the Total/HDL values for me). Furthermore, the EMR should predict what I might want to do next and offer up those options to me (e.g. refill a med, order another potassium test, etc...). The result is LESS CLICKS - I don't need to go looking everywhere for data or orders- the EMR has brought them to me!!!

I talked in depth on this topic at the recent HIMSS conference and hired several graphic designers to actually build out some of these concepts as either screen shots or flash animation - these are by no means perfect, but they give some sense of interfaces that take advantage of how an EMR can make workflows easier. They will hopefully stimulate more thought and ideas in this area. The PPT below provides a summary of this talk (although I could not figure out how to upload the flash applications - so it will all be static screen shot here). I used SlideShare to upload the PPT and embed into Blogger:
Post-Blog stories of interest
Wired magazine "re-imagines" lab reports:


  1. Nice blog, Lyle. I love the powerpoint - especially the different problem list models.

    I do disagree with you a bit about interoperability. It is certainly true that far too much governmental and media attention has been focused on our ability to remotely access our medical records when the vast majority of us can't do it very effectively locally. However, HIMSS analytics EMR adoption model tells us that 85% of all hospitals have electronic lab, rad and pharmacy systems. Surely there is enough data in those systems to support the creation of a bare-bones HIE network. Isn't that a valuable and achievable goal? Isn't that the point of the Churchill quote you used?

    If your argument is that we should not take our eye of the goal of broad-based adoption and usability, I agree completely. I'm just not sure this is an either-or proposition.

    Good luck with the blog - you're off to a great start!

    George Reynolds

  2. You highlight some important points in this post - especially re: the need for greater usability in EMRs.

    I recently posted on this topic. You can read it here:
    Human Factors Can Assist with Appropriate Implementation of Health Information Technology

  3. Dr. Lyle. I agree with your 3 points. I am most intrigued by the interface issue. As a fulltime practicing nephrologists I have been using 3 different EMRs in three different environments (Hospital, Office, Dialysis Unit) for the last 5 years. The Office system is the most complete but also has the worst interface. I struggle with how to get the vendor (Allscripts A4) to see the issue and develop interfaces that add value to the patient encounter. Each day I’m in the office I struggle with screen presentations that not only do they not add much value they actually act as an impediment to quality data transfer. When I try to deal with the vendor and programmatic IT team it is like hitting my head against a wall. I have to assume that developing a GUI and efficient functionality must be a very difficult task indeed. It clearly must be easier to let the data deliver the functionality vs. making the functionality deliver the data. Take a simple CBC for instance. There are 17 data points (Hbg, Hct, WBC, Plts, MCV, MCHC, RDW...) but in reality every clinician knows the first 4 are most important. Not that the remaining 13 aren’t important; just most of the time not important. From a programmatic stand point it is easier to deliver all 17 data points and let the end-user/clinician dig thru the noise to find the signal. This signal to noise ratio in EMR products esp. A4 but really all 3 of the products I use on a daily basis are a major drawback. When I try to discuss this with the vendor I am reminded that they already have “expert clinicians” who have helped with the development process and current interface is what is desired. How can this be? Am I missing the boat. Is my ability to filter noise somehow less developed then these expert clinicians?

    Thanks For all you do for my patients AO

  4. picuomaha - I think we are on the same page, I am not saying we shoudl ignore interoperability, I'm just saying we should keep some perspective- it is not the answer to everything. We should spend enough time to make sure local systems can talk to one another, and then spend more time on making sure the systems are usable... we can then figure out national interoperability later on.

    Eric- Wow, great blog- I'm starting to follow you!

    Dr. O - unfortunately, you got it... don't let them make you think otherwise. Ane believe me, I've been involved with EMR vendors for many years- and the problem is (1) Most docs simply can't easily express what they really want/need... they just accept what they get, and (2) The marketing dept too often pushes for a "look" that will sell to newbie docs who have never used an EMR. Bottom line- keep pushing the, the squeakie wheel usually gets some oil!

  5. Of course usability is a main issue with EMR. I am glad this issue is finally being discussed.

  6. Gorgeous blog and nice to meet all of you. you are saying absolutely right about EMR software. The EMR software is an important tool for health service institutions.

  7. Anonymous9:02 AM

    You are an important figure in the electronic medical record debate. I need to understand why we are promoting expensive solutions when the solutions already exist. For example, HIPAA compliant encrypted file sharing over the internet already exists (Bunkermail is one example). Why are physicians being forced to purchase software solutions that figure in the tens of thousands of dollars. Why is the individual physician being drowned by big business with big costs?


    S.Karos, MD