Poor design hampers EHR usability, doctors say

Difficulty finding patient information, problems navigating between screens, an overreliance on checklists as opposed to unstructured data and struggles with developing patient-specific problem lists are among the litany of complaints doctors cite when asked about lack of user-friendliness in their EHRs. 

To Mark Friedberg, MD, MPP, an internist and senior natural scientist at the Rand Corporation in Boston, these problems all spring from the same source: poorly designed technology.

“Good design is supposed to make it easy for a user to do the right thing, and in a lot of ways we’ve achieved the opposite in EHRs,” says Friedberg, who was not part of the survey. “The people designing them may be good at things like how to organize a database, but for actual human factors, putting together a tool so that it’s intuitive to use, in general they’re terrible.”

Friedberg, who uses Epic, cites the example of information clutter on the system’s screens. “We actually had to buy larger monitors to be able to use Epic because there’s so much crap on the screen,” he says. Moreover, the information presented often isn’t what he needs for treating his patient.

“So you’re constantly hunting around, scrolling, clicking out of tabs,” he says. “Good design requires design experts who can say, ‘Here’s how a display should look for a doctor who has to solve this problem at this time.’ But right now no one is providing that.”

For Jeffrey Kagan, MD, an internist in Newington, Connecticut and Medical Economics Editorial Advisory Board member, a user-friendly EHR is one that would enable him to track when patients arrive and are roomed, something his current system, gloStream, can’t do.

As a result, he sometimes encounters patients who complain they’ve been waiting a long time in the exam room-only to find out later that the patient arrived late for their appointment and had to be seen out of sequence.

Similarly, he says, “You want to know who’s not paying their bills, who’s not showing up for appointments, who’s not showing up for referrals. Unless that provider sends me a fax saying Mrs. Jones didn’t keep her appointment, I have no idea.”

Poplin, a survey participant who practiced for most of her medical career at a Washington, D.C.-area military hospital, objects to trying to capture the nuances of a patient’s condition via a checklist, rather than unstructured text.

She recalls the early days of her residency when nurses would provide her with detailed notes about any changes in a patient’s conditions since she’d last seen the patient. But when the hospital changed from paper to electronic records, information was transmitted instead via standardized checklists.

“That kind of information is useless to me,” she says. “I want to know if the patient is feeling better or worse. That’s not structured data, but it tells me a lot. For instance, if he’s having chest pain I need to know what the pain is like, how he described it. When people have chest pain, you have to write what they actually said, so you can know the next time whether it’s the same thing or something different. You don’t get that through a checklist.”

Poplin attributes the reliance on checklists, as well as many other features of current EHRs, to the fact that the systems are designed primarily as management and performance measurement tools. Referring to her residency experience, she says “My point is, an EHR that’s primarily for taking care of patients will look quite different from one that’s designed to manage.”

But Christopher Apostol, DO, a primary care physician in an Evans, Georgia-based group practice, thinks some doctors bring their frustrations with EHRs on themselves, either by expecting too much of the technology or not taking the time to learn it thoroughly. 

“A lot of times doctors want to customize their EHR instead of using the tool as it was designed,” he says. “I think you need to view the EHR more like an autoscope. I can’t make the autoscope do things it wasn’t designed to do. I have to use it for what it is. And that’s what you have to do with the EHR.”

Apostol, who was not part of the survey and whose practice uses athenahealth EHRs, says he’s satisfied with most aspects of the product, in part because he understands what it can and can’t do. “But what I hear from physicians not liking theirs is usually because they haven’t spent enough time learning how to use it properly,” he says. “Of course there can always be improvements, but I think in general doctors need to spend more time understanding what they bought and what they’re using so they can use it to its fullest.”

Mackie (athenahealth): It’s incredibly depressing that healthcare is the only industry that has managed to lose productivity by going digital. Many EHRs are still little more than glorified databases, hijacking physicians’ time with clerical work while patients receive less attention. Part of the failure lies in the original concept: EHRs were made for documenting information to support billing and defend against malpractice, not for improving care delivery.

athenahealth’s EHR is better than most, but to be honest, we’re a leader in a really bad lineup and there’s a lot of room for improvement. There are several things that we’re prioritizing and investing in to remedy this.

We’re investing heavily in mobile, which allows our customers to use touch and voice technologies more fluidly and gives them more freedom to connect during those “in between” times outside of a clinic or hospital.

Comments from physicians like Dr. Poplin have motivated us to provide a more natural documentation process and bring back the patient’s health story. The EHR needs to do more work “behind the scenes”-structuring narrative and voice input and synthesizing disparate data from throughout the healthcare network into easily digestible summaries of what’s happening with a patient.

Dr. Friedberg is spot on: There’s too much crappy information in EHRs. But this problem won’t be solved with just a user interface overhaul. Our cloud-based network gives us the ability to see what information providers are clicking and spending time on. We can learn from this aggregate user behavior what data are important and should be brought to the front versus buried a layer deeper. We can do this by specialty; we can do it with orders; and we can share and encourage best practices within a health system or across the entire country.

We’re not done yet, but we’re getting close.

Cuthbert (MEDENT): These comments make a lot of sense. It is an art form designing software that needs to handle fairly complex issues to accomplish what is needed, all the while being simple, fast and efficient for the user.

Systems should allow the user to place the clinical information in positions on the screen where they want to see it. This will provide the user with some control over how they are able to view all the information they need to see. It gives them the ability to process the information in best sequence for them to provide the best level of care for their patients. Taking advantage of space on the screen with sidebars that can be customized and optimized should be available as well.

Key information such as balance, wait times, recent results and disease management tools are a few examples of items that should be within an eye’s reach. Also, it’s worth noting that our product can document the progress note in various ways.  Sometimes, speech recognition can help efficiently record the patient's visit. Speech technology has come a long way recently and EHR systems can take advantage of these advancements to provide a high level of flexibility. Being flexible puts the user in the driver’s seat.

There is no question that most users can benefit from investing more educational time into their system. Having brief educational videos available, at the point of workflow, can be very helpful. Sign up for e-newsletters, attend user group meetings, or call in to support with any questions. You may be surprised at the functionality available that you may not be aware of. I think as a vendor we need to take initiative to provide that knowledge and empower the user.

Frantz (NextGen): We understand that our clients are experts in care delivery. We never want to shoe-horn our clients’ workflow into our technology and processes. Instead, we focus on enabling clients to work the way that they want to work, and we meet them wherever they are in the transition from fee-for-service to value-based care. We provide a platform that adapts to their business and work jointly to tailor the system and processes, to deliver on their business management, patient and caregiver satisfaction, and population health management goals.

It’s open conversation that starts before implementation and continues with our dedicated account management resources and specialized professional services team who provide best practices and insights to optimize the existing investment in HIT.

We take a consultative, proactive approach, offering hundreds of complimentary classes for clients focused on implementation, business optimization, regulatory requirements and quality initiatives, to name a few. And based on our clients’ feedback, we are focused on increasing opportunities for peer-to-peer best practice sharing, via our in-person user group meetings and our online client success community, which is available 24/7.