EMRs require better user-centered design

Healthcare IT News recently asked, “Do doctors have to be typists to get MU incentives?”

That question reminded me that given the many hours of unreimbursed labor performing EMR data entry at end of day, a significant chunk of a clinician’s workday is spent performing medical secretary services. Let me set the record straight, I am a good typist.  But EMR data entry interfaces are often unnecessarily cumbersome, so clinicians put off the majority of data entry until end of day to avoid falling utterly behind schedule.

Even the sign on process can be painfully slow, which discourages contemporaneous use of the system, especially when visits get repeatedly interrupted to speak with outside physicians by phone or to deal with patient complaints at the front desk, requiring securing and signing on multiple times in one visit.

The lack of user-centered design combined with cash infusions to encourage the purchase of systems that need further refining and that will be expensive to fix given that they are sunk costs is alluded to in the Healthcare IT News article’s discussion.  Specifically it discussed “whether or not current certified EHR systems allowed for decision support to appear again after the order is entered. Most of the physicians in the group said it was not possible. At least one said it was. Tang said to make Calman’s idea possible, it would probably require most physicians to have their EHR systems reprogrammed. Not a feasible idea, he said.”

That discussion brings to mind those pesky modal windows that fire alerts when a patient record first opens, freezing the system, forcing the user to deal with the alert in a definitive way at that moment, hence the reminder is not available when it actually is needed. Along that line, vendors and consultants often encourage clinicians to redesign their clinical workflows, not necessarily in a manner that makes clinical sense – i.e. not akin to the workflow changes one may enact when e.g. performing Lean improvement, but in a manner that will match how programmers wrote the EMR code.

In March, the Human Factors and Ergonomics Society held its first Symposium on Human Factors and Ergonomics in Health Care: Bridging the Gap. Despite all the vendors in the EMR space and the current lack of incorporation of basic user-centered design and human factors principles in many products, only Athena Health, to which I have no connection, participated in the Healthcare Information Technology track of that symposium.

Rather than relying on lobbying power to maintain market share, it would be refreshing to see vendors embrace human factors and user-centered design principles, along with modern languages and architectures, to create better systems that enable clinical quality, safety, efficiency and effectiveness.  Hopefully, EMR vendors will see value in participating in next year’s HFES Health Care Symposium and in incorporating such principles in their products.

Barbara J. Moore is a pediatric pulmonologist and medical informaticist. She is a clinical adjunct faculty member of Northeastern University’s Masters Program in Health Informatics and consults for healthcare information technology companies and healthcare providers.

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  • SiMBa37

    for anyone else wondering, here is the link to the article referred to above:


  • buzzkillersmith

    The sin in EHRs is having been born.  EHR data entry was cumbersome, is cumbersome, and shall ever be cumbersome.  No magic app is gonna save us with this misbegotten monster of techo-insanity, doc.  On the positive side of things, the vendors are making some serious money; pity about how we spend our evenings, but they’ll get over it.
    In our practice we dictate and the transcriptionist does the work of getting the info into the EHR.  Making the best of a bad job. All other methods of wrestling with this beast are simply doomed to failure. Next case.

    • southerndoc1

      Ah yes, the EMR AND the transcriptionist: one of those great cost-savings we were promised. Now if you add a scribe, you’ll really be rolling in it.

  • davemills555

    The answer is easy… Stop trying to be the 1950s version of Marcus Welby! Stop trying to run a single-doc office, where a great majority of your time is spent being an office manager! Join an ACO as a salaried employee and you’ll be amazed how much time salaried medical professionals spend doing the thing they love most, caring for their patients. In the ACO environment, from the moment your shift begins, you are doing the things you learned in medical school and you are leaving the office management chores to those who know those skills best. To be sure, you were never trained to be an office manager! Do yourself a favor. Stop fighting the ever growing migration into the new world of health care delivery! Oh, by the way, it might be to you advantage to catch up with the rest of us in the 21st century and learn to embrace the use of a computer and brush up on your typing skills. How hard can that be? Huh?

    • kjindal

      “In the ACO environment, from the moment your shift begins…”

      exactly – lets all become uncaring punch-in punch-out somebody-elses-problem leave-me-alone-after-my-shift workers, like many the mentality among nurses, therapists, and many many other ancillary types. The dumbification of medicine by the corporatists, let it proceed unfettered.

      • davemills555

        Sounds to me like you are very frightened by ACOs. Why is that?

  • swestfisher

    Most software development companies give their programmers a pretty free hand in design. Even when development is being driven by an Architect, that individual is also a programmer at heart. This causes the underlying data structures and algorithms to show in the end user interface, leading to confusion by medical staff end users. This confusion is seen by the vendor as a training issue, not a problem with the software.
    After 27 years in healthcare software development, I believe there is a fundamental difference in the thought process between programmers and medical staff. If vendors were to have medical subject matter experts (who think like typical end users) on the development team, and for them not to be overridden by the developers on the team, I believe EHRs would be far more intuitive and useful for end users.

    • bobcolimd


      One clear example of the lack of human-centered design in the 2,163 ambulatory
      and inpatient, complete or modular EHR products which have received  ONC-ATCB 2011 certification foe Stage 1 MU
      criteria or the 97 EHR products that have received CCHIT 2011 certification is
      the variable formats they use to report cumulative diagnostic test results as
      incomplete and  fragmented data.


      This flawed user interface design hasn’t changed since mainframe computers and
      dumb terminals were first introduced into hospital in the 1960s.


      starting with the Direct Project in
      January 2010, ONC’s efforts to combine the open source collaboration and open
      government models to develop “standardized” transport, vocabulary and content
      exchange standards (http://wiki.siframework.org)
      is already starting to disrupt HIE 1.0 and
      incentivize health IT vendors to improve the usability of their products and
      compete long term on ease of use and total value for users. (http://news.avancehealth.com/2011/05-11/emerging-standards-and-disruption-of.html


      logically simple, but complex to create solution is the development of a
      clinically intuitive, standard reporting format that can display cumulative,
      integrated test results information on up to 80% fewer screens and pages and
      enable physicians and patients to view and share it efficiently for the first


      Coli, MD

  • ReasObBob

    centeredness is not required to qualify for MU incentive$.  It’s simply a speed to market and bottom line
    issue for MOST health IT vendors.  Some
    DO care, but small percent.  We will be
    announcing a new approach by EOM.

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