Why EMR companies don’t care about usability

I overheard nurses praising the pilot of a new technology with the promise of improving communication, safety, and saving on healthcare spending. The innovation: two-way texting. That’s one of the many indicators that hospitals are stuck the technological stone age.

Imagine how many eyes light up when you offer providers fewer logins, autopopulating forms, and uncluttered menus. There’s an assumption that technology, in the context of healthcare, has to be bad (sometimes attributable to security and privacy). Physicians in the hospital often complain about “technology” as a whole. Outside the hospital, people are constantly evaluating the metric of EMR adoption. In reality, there’s good and bad technology, and there are good and bad EMRs.

What we in healthcare need to realize is that internet companies over the past ten years have developed processes for developing adaptive, secure, and user-friendly technologies. We love our online banking, shopping, and emailing. Meanwhile in healthcare, everyone seems resigned to using poor, outdated technologies by established vendors that have lost the incentive to innovate.

We all know EMRs are painful to use. These systems are reminiscent of software from the 90s, with inconsistent menus, obscure placement of data, and overwhelming numbers of buttons. It’s not uncommon to traverse ten menus to order a routine laboratory test, or to miss a critical note or lab value hidden in an obscure screen. This is frequently compounded by so-called decision support, frequent pop-ups that are more likely to be irrelevant than genuinely useful. If the 16 hours of training required just to start using EPIC are any indication, these EMRs are not built around their users’ needs.

Why is usability neglected? The first reason is the way EMR purchases are incentivized. As the New York Times reported earlier this year, there was extensive lobbying by the EMR companies that subsequently became much richer after passage of meaningful use. The five major EMRs that now hold control of 50% of our major medical centers and a similar amount of our patient data are some of the least effective systems that I have used. This is due, in part, because meaningful use has failed to emphasize the importance of design and open data in health information systems.

Here’s another reason: The predominant users of EMR systems — and most technically literate people — in academic medical centers are the resident physicians, a group usually left out of purchasing decisions. Residents can spend 2 hours each morning just aggregating numbers from various clinical information systems into a usable format. These data go into an alternative data-management system, often a Word document, to logically present the roster of patients and pertinent data. Because existing systems fail to organize information in a way that makes sense to providers, providers resort to these workarounds, and spend time manually aggregating data from electronic systems. In satisfying meaningful use, hospitals are less able to prioritize workflow. Hospitals need to demand try-before-you-buy periods where the residents and staff who will actually be using the system can voice their feedback and specify changes.

Driven largely by consumer demand, software companies have been greatly advancing user interface design over the last 10 years. These companies have developed a well-defined process for building good software known as agile development, which emphasizes frequent user testing and iterative development. This commitment to user satisfaction has not touched healthcare. After hundreds of millions of dollars are invested by the institution just to deploy EMR software, the switching costs are simply too great to consider other options. Thus, there is little incentive for enterprise EMR software manufacturers to continue to improve.

The healthcare industry still has much to learn around the design and usability concerns espoused by Silicon Valley. Innovation in user interface has really been carried by the many small companies that have defined a process for user-centered design. Institutions like the Mayo Clinic, Beth Israel Deaconess Medical Center, and Vanderbilt University have in house development teams who listen to user feedback and continuously improve their EMR offerings. While not all hospitals have the resources to support a development team, hospitals need at least to demand better solutions. Administrators need to stop looking at EMRs as off the shelf solutions and meaningful use as a checkbox item. Only then can we leverage the power of technology to improve patient care.

David Do is chief technology officer, Symcat.com.

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