But now that federal EHR incentive programs have inspired more widespread use, the health I.T. industry and regulators are acknowledging that clinicians have been right all along: many EHR user interfaces are awkward and non-intuitive, and they hinder more than they help.
The design issue is growing in prominence. For one thing, engaging, simple interfaces on the iPad, the iPhone and Android smartphones, and the Internet-all embraced enthusiastically by the health professions-have given users new ways to interact with their devices. The bar has been raised.
Beyond that, poor EHR design might be a patient safety issue. The Institute of Medicine's (IOM) November 2011 report, "Health IT and Patient Safety: Building Safer Systems for Better Care," cited lack of usability as one potential cause of errors in using EHRs: "Poor interface design that detracts from clinician efficiency and affinity for the system will likely lead to underuse or misuse of the system." While the hazards of poor design haven't been quantified in any large-scale studies, hair-raising anecdotes are plentiful: medication lists broken up over several pages, positive lab results buried in long lists, and notes cut-and-pasted from one section of the record to another without requiring a check to see whether they're still valid.
There are many factors why EHRs often can be so unpleasant to use. At the heart of the matter, vendors don't understand what clinicians really need, sources say. To make matters worse, vendors often try to limit information sharing about their products. And even among clients of the same vendor, system customization can result in a wide variety of system configurations that make learning from what others are doing difficult. But experts suggest several tips in vendor selection to help sidestep potential problems. And defining the characteristics of a "usable" system helps as well.
There's no doubt that, at best, EHRs often get in the way. "The physician's day is a large set of interleaved tasks, and the tools should be designed to facilitate the safe conducting of that work," says Scott Finley, M.D., senior physician informaticist at the research company Westat, Rockville, Md. "Most health I.T. tools tend to slow users down." Finley consults on usability issues for the Department of Veterans' Affairs, the Agency for Healthcare Research and Quality, and the Office of the National Coordinator for HIT. He says most EHRs are bad at helping physicians juggle the simultaneous tasks they all face, like answering a question about one patient while in the middle of writing a prescription for another.
Much of the power of EHRs lies in their ability to gather structured data for downstream analysis, but Finley says that focus can hurt usability even more by constricting the way clinicians can enter data. "The data capture process needs to be judged on its own merits," he says. "It's easier to make it hard than to make it easy."
A flurry of regulatory activity is likely to result in usability being added-somehow-as a criterion for EHR products to be certified for meaningful use incentives. ONC says it's currently crafting a proposed rule addressing EHR usability. The office declined to comment on specifics. The National Institute of Standards and Technology, which held a workshop on EHR usability last summer, has at the ONC's behest, developed guidelines for usability testing. They are now out for public comment. The ONC's proposed rule will likely focus on how vendors test usability, rather than on specific characteristics of the user interface.
Why so bad?
Why are EHR user interfaces generally so bad? For starters, many of them originated years, or even decades, ago, before today's sophisticated interface tools were developed. "Sometimes what you want to do on the front end requires significant change on the back end," says Ted Shortliffe, M.D., president of the American Medical Informatics Association. "It's not just a matter of mucking around with the interface. And retrofitting a large base of existing systems is extremely complex and expensive. Many vendors shudder at the thought."
Lack of understanding of what clinicians need is at the heart of problem. It's not that vendors don't ask users what they want-far from it. Every vendor has armies of advisors with medical and nursing degrees, but advice isn't enough-or even useful most of the time, says Paul Tang, M.D., vice president of innovation and technology at Palo Alto Medical Foundation, and a national leader in effective use of HIT. Instead, software developers should be standing at the user's elbow watching what he or she does all day, and then figuring out how the EHR can help. "Observing customers in the field is far more effective than listening to folks tell you what they would like to have," Tang says.
Users generally don't know what they need, says Scott Plewes, vice president of user experience design for software developer Macadamian, which specializes in interface design for health I.T. and medical devices. "They'll say, 'I need a big red button in the middle of the screen,' but they're not designers-they're experts in what they do. It's very hard to get good insight into their needs and then turn it into a good design."
Lack of information flow among vendor customers is another issue. Vendors are understandably protective of their intellectual property, which includes the appearance and function of user interfaces. Contracts frequently limit how much information customers are allowed to share about the interfaces.
Computer science professor Ben Shneiderman of the University of Maryland specializes in human-computer interaction and has a particular interest in EHRs. Asked whether EHR interfaces have improved recently, he says he so rarely sees them that he has no way of knowing. "The problem is that this industry is closed," he says. "You talk about the iPad and everyone can buy one and see one, but no one will show me an EHR interface without my signing a nondisclosure agreement. The public has a legitimate right to have these products reviewed by professionals in the usability field."
