In what is clearly good news for emergency providers, a handful of the nation’s top IT companies, including Allscripts Healthcare Solutions, Epic Systems Corporation, Athenahealth, Cerner Corporation, and Meditech, are pledging to push interoperability — a move seen by the Obama administration as a critical first step toward achieving a goal that emergency providers in particular have long coveted. When announcing this agreement on Feb. 29, Health and Human Services Secretary Sylvia Burwell explained that the companies have agreed to do three things: help patients more easily access their electronic health information and transfer it to any provider or data user, help providers share patient health information with patients and each other, and to implement federally recognized national interoperability standards and best practices.
But even with this welcome development, there is no question that emergency clinicians have valid concerns about the usability of their electronic medical record (EMR) systems. Many of these systems aren’t configured to fit well within the workflows of busy emergency providers. Indeed, a common provider complaint is that the EMR he or she is using apparently has been designed with some other stakeholder in mind, certainly not clinicians. Further, while many EMR vendors conduct extensive usability tests before rolling out new features or programs, studies show that a number of vendors are not meeting required standards in this regard.1
However, while EMR vendors have plenty to answer for in the way they configure their products to meet end-user requirements and patient safety standards, are there steps that clinicians themselves could take to improve their own usability experience? To answer this question, ED Management reached out to EMR developers to get their take on some of the biggest provider gripes, and what clinicians could be doing to make their own EMR systems a better fit for their needs.
GET IN THE GAME
Most vendors agree that one of the most important things that clinicians can do to improve the usability of their EMR systems is to make themselves available when vendors are seeking feedback or opportunities to observe workflows.
“We need clinicians and organizations to be supportive of that and to make that happen,” explains Ross Teague, PhD, the senior manager of user experience at Chicago-based Allscripts Healthcare Solutions. “More and more HIT [health information technology] developers are understanding the value of user-centered design, and what is at the core of that is being able to learn about and from end-users.”
Teague notes other industries that get high marks for the usability of their software systems do not necessarily have better designers or developers.
“It is because they have a better and deeper understanding of who their users are and what they are trying to accomplish,” he says.
Kris Engdahl, MS, the senior manager of user experience at Watertown, MA-based Athenahealth, agrees with these sentiments.
“We like to visit before we start designing to get a real sense of what it is like for doctors, nurses, and other clinicians to do their work because we sit in a room, write code, and talk to each other. That is really different from the environment that our users are in,” she explains. “We try to get out and see, then we design, and then we test with our users.”
However, Engdahl acknowledges that finding clinicians willing to participate in these usability tests can be difficult.
“It is a challenge across the industry to get real users to spend time trying things out,” she says. “We work through our account managers and support people and anyone we can to find our own physicians, nurses, and medical assistants … who are most willing to spend time with us.”
Even a small amount of time spent participating in usability tests can deliver big dividends, Engdahl observes.
“If [clinicians] give us half an hour, it is going to pay off multiple times within a month or two when we release a feature that we are testing,” she says.
In fact, Engdahl suggests providers need not wait for an invitation to engage in the EMR development process.
“Invite [your EMR vendor] to send someone from their development team to watch what goes on in your department,” she says. “They don’t have to be in the middle of it; they don’t have to be in the way. But if they can come and watch what it is like for you to do your work for a day ... it helps them to know how to understand the problems you are having.”
Further, any time an EMR vendor asks for feedback, give it to them, Engdahl advises.
“If they put a survey up, answer it, and let the crankiest doctor do that,” she says, noting that physicians who profess to be the least proficient with technology are the physicians she most wants to hear from.
“Let your vendors see you in action, get a better sense of who you are, and be part of their testing program,” Engdahl says. “If you offer that and they aren’t interested in it for some reason, keep talking to them and encourage them to have you do more visits.”
INSIST ON FORMATIVE TESTS
While it is important for end-users to engage with their EMR vendors, Teague advises clinicians to stipulate that they are interested in participating in formative tests, not demos.
“A demo means showing people what a product does,” Teague notes. “A formative usability test, which is really part of a user-centered design process, is when I place one person in front of [a computer] ... and ask him or her to show me how he or she would [use the EMR system] to prescribe a medication.”
Developers discover the majority of usability problems during formative usability tests, Teague stresses.
“This is where you catch the most patient safety issues or potential patient safety issues,” he says. “Demos are fine if [a vendor] is trying to show what features an EMR product has and what the product can do, but if you really are trying to improve the usability of your product, demand formative testing.”
However, offering input to vendors must be more than a one-time thing, according to Christopher Alban, MD, MBA, an emergency physician and a vice president at Epic Systems Corporation.
“Providers should maintain regular communication with their vendors so that they can provide the vendor software developers feedback directly as much as possible,” he says. “Phone calls, conferences, webinars, visits — these are means to getting direct access to programmers.”
For example, Alban notes that in addition to assigning dedicated support staff to each customer, Epic hosts an online forum where users can post suggestions or engage in direct discussions with software developers.
“Before a new version of our software goes out, customers help set our priorities through suggestions, our ED advisory council, and [our] ED steering board,” he explains. “During our conferences, we have usability stations so customers can get hands-on time with new features and give us feedback. Some customers take early cuts of the software to test.” (See below: "Maximize EMR value, usability.")
Teague advises healthcare organizations to go beyond the vendor-sponsored usability tests and conduct their own usability evaluations.
“Very simple usability tests will reveal issues early because we are always opening new modules to people, and they are rolling out new procedures and workflows with the tool that has already been in place for a while,” he says. “Benchmark what you are doing and evaluate against that. Have clinicians try [specific] tasks, observe how [the system] works, and collect metrics.”
Such activities prompt end-users to consider how they would define good usability.
“Is it that someone can do a task without errors? Is it that it takes less time than it did before? Whatever that might be, evaluate against it,” Teague advises. “Once you get into a complex environment with technologies and social aspects, things change. I encourage people to conduct their own evaluations.”
CONSIDER SAFTEY/EFFICIENCY TRADEOFFS
Clinicians often complain that it takes EMR vendors way too long to fix a feature that has emerged as problematic. Engdahl responds that the turnaround time for a fix depends greatly on the nature of the problem. For instance, given that the Athenahealth EMR is cloud-based, a glitch or serious problem can be resolved on the day it is reported, making the fix available to all end-users of the EMR right away. However, she observes that many complaints require further study and development time.
“Most features that people have been using that they are unhappy with need some time for consideration of what the problems are, what other clients are doing, and trying to figure out whether the issue has to do with [the specific client’s] configuration ... or if it is a problem that other people are having that we need to fix at the program level,” Engdahl explains.
Further, clinicians need to understand that there are some tradeoffs between safety and usability at times, Engdahl adds.
“Usability is efficiency, effectiveness, and satisfaction. That is the ISO [International Organization for Standardization] definition of usability, and most of us in the human factors profession use that as our definition,” she says. “But a lot of safety features that are required or recommended actually impede your progress to make you stop and think is this really what you want to do.”
It is not unlike safety procedures that take place outside the EMR, Engdahl explains.
“We are about to perform a surgery. Everybody stop, tell us your name, and let’s reiterate what we are operating on and which limb it is,” she explains.
Similarly, in an EMR a safety alert may pop up warning the physician that a drug he or she is in the process of ordering for a patient can interact adversely with another drug that the patient is taking.
“This might come up as a box that the physician has to dismiss and people get really annoyed with it,” Engdahl notes. “In that case, you are always going to have some tension between safe practice and efficiency.”
Engdahl argues, however, that there are many other instances in which the poor usability of an EMR feature actually impedes safety.
“It may make it harder for people to see all the information they need to see all at once to make a decision,” she says. “Then it is affecting both usability and safety. They are not antagonistic to each other, but there are times when there is a tension.”
Fortunately, most of the time, speed equals safety, Alban observes.
“You want all the information to be instantly available to the right person at the right time. However, when it comes to designing your decision support system, sometimes slowing an ordering process can improve safety,” he says. “For example, an antimicrobial stewardship program may restrict the use of certain antibiotics to lower the risk of that patient acquiring a hospital infection like C. difficile.”
Frontline clinicians often count clicks as a way to quantify efficiency, Teague notes, but it only tells part of the story.
“How many of those clicks were unnecessary? How many of those clicks sent something to five different people such that you didn’t have to write something out,” he asks. “My goal is to reduce as many unnecessary clicks as possible. When I am talking with clinicians about efficiency, I don’t want to get too caught up in clicks because ... there are too many times when there is a good reason for them.”
GO EASY ON CUSTOMIZATION
Recognizing that EMRs serve many different functions within a hospital setting, Teague emphasizes that hospitals need to use a systems approach when implementing an EMR product.
“When you are making decisions about what your workflows are going to be and how the product is going to be used, you have to consider every stakeholder in the system,” he says.
Teague acknowledges that clinicians have a point when they note EMRs tend to optimize for billing or other administrative work rather than for clinical care. But he stresses that you cannot optimize for everybody in a complex system.
“In this very complex environment, when you focus on one area, something else is going to be affected by that,” he says. “That systems approach is a big thing that I want clinicians to understand. In a lot of cases you are in a system, and a lot of the decisions have been made that the vendor doesn’t have anything to do with that are affecting your experience.”
Further, when it comes to personalization and customization, Teague advises clinicians to take it easy.
“It is great for clinicians and organizations to be able to tailor software to fit their workflows instead of having to force-fit themselves into what the tool wants them to do, but we see often clients or organizations customizing their software in a way that creates usability problems,” he explains. “They will choose fonts, background colors, or an organization of information that they think they are going to like, but it actually reduces readability, reduces intuitiveness, and increases cognitive load.”
Sometimes, Teague hears from clients about a screen or page in the software that is problematic. They ask why the software developers designed it that way.
“In the nicest way possible, I have to say we didn’t design it. It was customized by [the client] or changed by someone in [the client’s] group,” he says. “Be careful with customization.”
In Teague’s experience, both sides working together effectively can solve most clinicians’ gripes.
“You mitigate 90% of the problems through communication,” he says, noting this may involve explaining to clinicians that what they are asking for is less efficient or doesn’t fit well with what they are trying to accomplish. Perhaps the desired feature will take time to develop, but at least the clinicians will feel as though someone’s noticing their concerns.
What’s more, vendors and clinicians often can work together to replace a feature or function with something that is more familiar and, thus, easier for the clinicians to use. For example, many emergency physicians lament that they have transitioned from home-grown ED information systems that fit their workflows like a glove to system-wide enterprise systems that are not geared to their specific needs. In these circumstances, Teague endeavors to identify what specifically the clinicians liked about the old system, and then leverage interface paradigms with which the clinicians are familiar so that the clinicians can better adapt to the new system or function.
The interface paradigms may come from other areas such as Amazon or common e-mail platforms, but when the way that they work is familiar, clinicians intuitively adapt to using the new functions more readily, Teague explains.
“That is a way of making a change to something that [clinicians] don’t want changed, but doing it in such a way that they are able to use it and become efficient with it again.”
REFERENCE
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Ratwani R, et al. Electronic health record vendor adherence to usability certification requirements and testing standards. JAMA 2015;314:1070-1071.
SOURCES
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Christopher Alban, MD, MBA, Emergency Physician; Vice President, Epic Systems Corporation, Verona, WI. Phone: (608) 271-9000.
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Kris Engdahl, MS, Senior Manager, User Experience, Athenahealth, Watertown, MA. Email: [email protected].
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Ross Teague, PhD, Senior Manager, User Experience, Allscripts Healthcare Solutions. Email: [email protected].
