Implementing clinical information systems at healthcare organizations can be a jarring experience. And when those systems conflict with long-used work processes for accomplishing clinical tasks, it's more than annoying. It can make an IT project a long, uphill slog.

For a health IT project to succeed, the flow of information must be synchronized with clinical workflow-that's how an organization can best ensure it will achieve significant gains in efficiency and quality of care. Conversely, when those flows don't match up, providers become less efficient, forced to take additional steps or create workarounds for incongruities.

Such synchronicity is hard to come by for providers. In fact, studies suggest that the rapid adoption of electronic health record (EHR) systems, spurred by federal incentive programs, have led to usability, workflow and cognitive support issues that hinder patient care.

Workflow impediments

Those are among the findings in a May report from the EHR-2020 Task Force of the American Medical Informatics Association, which offer a grim assessment of early efforts to use EHRs in clinical practice. The task force concluded that EHRs have disrupted clinical communications and workflow, while increasing workarounds.

"EHR systems often use alerts as a blunt instrument to inform and motivate clinicians, creating significant complaints and alert fatigue," the AMIA report says. "Designing EHRs to match work processes is difficult, but essential in order to maximize functionality and safety."

Interruptions to clinician workflows, caused by the use of information technology to capture increasing amounts of documentation, can cause crucial disruptions to the caregiving process, says Lana Lowry, health IT usability project lead at the National Institute of Standards and Technology.

Lowry warns that clinical workflows are extremely complex and multifaceted processes that are purposefully developed by providers and should not be trifled with. "These are licensed professionals who provide the standard of care. They have their clinical workflow that is supposed to be sacred. Nobody should be altering it, touching or deleting it, because this is how doctors and nurses treat patients," Lowry insists.

Documentation demands

The AMIA report offers recommendations for improving provider workflow, including simplifying and speeding documentation, which otherwise is a drag on workflow. "A lot of documentation is driven by [evaluation and management] codes and the way in which the CMS pays for medical care, and a lot of that has resulted in drop-down menus and check boxes," explains Doug Fridsma, MD, president and CEO of AMIA. The task force recommended reducing clinicians' burden for data entry. "It's sometimes frustrating for physicians when they're really just trying to capture the notion of the patient and their condition."

The task force estimates that physicians' time investment in documentation has doubled over the past 20 years and may consume as much as half of a physician's day.

"Although medicine requires an entire team to care for patients and to document the care patients receive, interpretation of CMS' requirements has placed the primary burden of office visit documentation on physicians," finds the report. "Much of the information relevant to the diagnosis and treatment of a patient could more effectively be entered by other members of the care team, captured automatically by devices or other information systems, or captured and entered by patients themselves."

There's no reason physicians have to do all the tasks associated with an EHR, says Sarah Corley, MD, chief medical officer for NextGen Healthcare. "It's always been important to adjust workflows so you have everyone working to the top of their license," Corley says. "If you don't plan your implementation well and analyze what you're doing and what you need to do differently, the default seems to be that the physician just does all of the new work."

Nonetheless, Corley argues that any time physicians start using an EHR system, they cannot do the same things they did with paper records if they expect to take full advantage of the features and functionality of EHRs to improve patient care. "You really do need to transform your workflow if you are going to be as efficient as you should be," she says. "That's always been the case with EHRs."

Workflow vs. usability

Still, there's a fundamental question that needs to be addressed-whether the EHR is impacting a preexisting workflow, says Amy Franklin, an assistant professor in the University of Texas at Houston's School of Biomedical Informatics.

"Saying that an adopted EHR is not seamlessly fitting in with the way you used to work or the way you want to work, that's very different from talking about a workflow within the EHR system and whether it is intuitive and effective in the way that you are being pushed through the system itself," asserts Franklin.

Issues with EHRs not being intuitive, navigable, easy to use or fast enough "need to be responded to by the industry," says George Gellert, MD, associate system CMIO at CHRISTUS Health in San Antonio, Texas.

However, EHR vendors have an inconsistent track record in addressing EHR design concerns that cause physician dissatisfaction, Franklin says. "Some systems, like the one used by the VA [VistA], grew organically over time with a fair amount of input from their end users," she points out. "Other systems may have come up with less user involvement. We've had a huge proliferation of EHR systems in the last decade. How they were built, the amount of foresight in their building, the inclusion of clinical perspective and knowledge of real-world needs, varies dramatically."

There's significant variation in the EHR market, agrees Eric Helsher, vice president of client success at Epic. The industry has many different vendors, providers, medical specialties and health systems-each with its own perspective on successful system approaches.

Nonetheless, Franklin maintains, part of the problem is that some EHRs were "cobbled together" as components were purchased or acquired across different existing systems, giving rise to usability issues. "Some of the clunkyness can come from that creation process," she concludes. The challenges in using EHRs are compounded by "the complexity of the work environment," which includes workflow and human factors that come into play in delivering healthcare.

Citing this complexity in healthcare, Epic's Helsher makes the case that EHR workflows need to be specific to the various medical specialties. "We see a big connection between user satisfaction and workflows that are set up around their particular specialties," he says. "Cardiologists have different needs from oncologists or psychiatrists."

Disruptive technology

"To think that you can build one EHR system and overlay it on myriad practice settings just doesn't work," agrees Debora Simmons, chief quality officer for CHI St. Luke's Health in Houston. Simmons, who has been involved with about a dozen EHR implementations in her career, calls it "truly disruptive technology" because providers have to "fit their workflow to the electronic health record, not the other way around."

Most EHRs are "designed in a vacuum," Simmons asserts. "Developers do not get out and work with users enough to know what they need" in terms of clinical workflow. "They've inherently put complicated, dangerous changes in their workflow," she adds. "EHRs are not built with sound usability principles."

Franklin at the University of Texas participated with a team of researchers that evaluated commercial EHR systems as part of the Strategic Health IT Advanced Research Projects, funded by the Office of the National Coordinator for Health IT. SHARP sought to study EHR usability, workflow and cognitive support issues.

"We performed a keystroke-level model in which we walked step-by-step through every click required to complete a task" such as entering an allergy alert or prescription, Franklin says. "We found that there were pretty significant amounts of time required to complete some tasks."

Hope on the horizon

But the good news, according to Franklin, is that EHRs can be redesigned to reduce the steps and amount of time needed to complete tasks. "The issue is finding a way to integrate the requirements of technology with the workflow you're trying to accomplish," she says. "That includes EHR usability and better understanding of how systems are used in actual work environments."

Epic's Helsher says some of his company's customers find they're able to spend less time and be more productive using templated EHR documentation tools. "Good training is the key to EHR success, both in terms of overall satisfaction as well as reducing the amount of time to complete their workflows."

Franklin agrees that training can help alleviate some workflow challenges experienced by physicians with EHR systems. "Training is often limited to an environment where they are given a very quick overview and are expected to use the system with 'elbow support,' so there's a lot of training with the expectation that 'you'll figure this out while you're on the floor,'" she says. "Also, training does not currently reflect the prior experience of these physicians using the system. Many doctors have used multiple EHR systems as they have practiced in different environments, but they are not trained on how those systems are different, so there is risk of errors where they might try to force the process of one system onto another."

Helsher advises that physicians customize their EHRs, adjusting a system's "look and feel" to make it more comfortable to use based on their preferences, as well as reorganize the various EHR sections to better serve workflows. In fact, he says, more advanced EHRs have "learning software" that knows a physician's preferred workflow and suggests different options based on his or her previous use.

Franklin concurs, but stresses that EHR customization requires ongoing usability assessment. "Many people want to tweak the system to better fit what they want it to do. Yet, when they are creating the system, they need to put a lot of time and effort into looking at the downstream implications of those modifications," she warns. "What you'll discover when you're doing usability testing is that if you want to test a process or procedure-given that different people touch it at different points-you really must consider what the implications are for any changes you make."

Specifically, Franklin cautions that if the look and feel of an EHR system is redesigned, the "good usability principles that were put in place beforehand" should also be maintained, and providers should assess whether these modifications might inadvertently "alter other workflows beyond the ones you're trying to change."


When it comes to increasing physician satisfaction with EHRs and creating better clinical workflow, the ability of clinicians to access EHR data on their smartphones and tablet computers is critical.

According to a September 2014 report from KLAS Research, "Global EMR Perception 2014: Usability and Integration Driving Mindshare," 74 percent of providers interviewed selected usability as the most important consideration and 61 percent indicated that clinician adoption/workflow issues are the top concern regarding implementation of electronic medical record systems.

Optimizing EHR software to run on mobile devices can go a long way toward serving the on-the-move needs of doctors making their rounds in hospital wards and examination rooms at physician offices, as well as accessing patient data from their homes or cars, says Eric Helsher, vice president of client success at EHR vendor Epic.

From Android smartphones and tablets to iPhones and iPads, mobility is becoming increasingly important for medical professionals who need to access patient records regardless of location, Helsher suggests.

"The primary method of accessing an EHR system is still definitely the desktop or laptop computer, where we can provide the most information and the tools for advanced ordering and complex documentation," Helsher says. "The mobile devices are intended to augment the physician workflow rather than replace the desktop or laptop."-G.S.

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