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 Meanwhile in healthcare, everyone seems resigned to using poor, outdated technologies by established vendors that have lost the incentive to innovate.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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  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    EMR companies care very much about usability, quality and client satisfaction. They have great software development teams, routinely use Agile methodologies and as much cutting edge technology as they can. Unfortunately, there is very little resemblance between a Silicon Valley useless social media app collecting your private information on behalf of corporate marketers and government secret services, and a transactional enterprise application which is what EMRs are.

    The reason EMR usability is unsatisfactory, is the same reason that prevents good and caring physicians from providing patients with the care they want to provide – overwhelming government regulations eating away at your time and resources and consistently crippling your performance.

    • southerndoc1

      Well said. Doctors need to remind themselves over and over that what they hate about EMRs is there because of CPT, ICD, MU, and HIPAA. Take those away and EMRs will be fantastic; keep them in effect and EMRs will continue to be a pain in the tush.

      I’m not optimistic.

      • David Do

        Southerndoc, thanks for weighing in. While the implementation of CPT and ICD has caused a lot of problems, I would argue that technology should help us integrate seamlessly with those standards.

        HIPAA can be a hassle when trying to share information between different healthcare entities, but currently there are problems sharing information between providers within the same institution.

        My argument is that, take those [regulations] away, and EMRs will still be a pain in the tush unless hospitals and physicians change the way the buy technology.

        • MarylandMD

          I agree. All this whining about government regulations is pathetic and unpersuasive. For many EMRs, the user interfaces were set up long before Meaningful Use. They were bad years ago, and the EMR companies simply haven’t moved into the 21st century in UI design. The most generous thing you could say is that the MU requirements took the the EMR user interface from “really bad” to “slightly more really bad”.

          • southerndoc1

            ” All this whining about government regulations is pathetic and unpersuasive.”

            Pointing out specific examples of how MU and CDS have interfered with the usability of EMRS, as Ms. Gur-Arie has done, is very persuasive and is the exact opposite of whining.

            I would posit the assumption that the entire enormous EMR industry is intentionally designing lousy products that still manage to sell like hot cakes as a much better example of whining.

            “the user interfaces were set up long before Meaningful Use”

            But not before CPT and ICD. Any EMR that is designed to integrate, seamlessly or otherwise, with such a profoundly dysfunctional system as CPT is, by definition, going to be non-functional for the users.

          • Michael Chen, MD

            Just out of curiosity, what would be a more ideal system or framework than CPT for you? (I agree, it’s dysfunctional and the fact it’s proprietary and costs something to have and use is in it of itself is a big red flag). I’m trying to envision how an EHR would function in an alternate framework that works for physicians. That’s the beauty of open source software projects like mine, i’m not tied down to strict interpretations of things…the ablity to adjust and cater to the workflows of physicians to ulitmately provide better care for patients is the goal.

          • MarylandMD

            I count one simple example: smoking status and smoking cessation advice. Capturing them for MU required turning them into “structured data elements”. What is the big deal? An EMR is **full** of structured data elements! Adding a few more is not a huge change. Assessing and maintaining a notation of a patient’s smoking status has always been a part of good medical care and having a structured data element for it should have been there from the beginning. As I said, the example given is not persuasive. The problems with the user interface of most major EMRs have little to do with MU or ICD-9 or any other jumble of letters you come up with, as several users in this forum have already attested to.

            I don’t think they are intentionally making them badly to torture us, just that the EMR designers don’t care about the actual front-line user to put the required effort into it, and the people making the purchasing decisions don’t seem to care much, either.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Let’s stay with smoking, although you understand that this is just one small example, I hope.
            Smoking could have been recorded in one of the following ways:
            1) A structured ICD-9 305.1 in the problem list, with perhaps an added comment like “1 pack a day”
            2) A structured social history element – smoker yes/no, with maybe a second level of “cigarettes” and a third level of “1-2 packs per day”, or another free text comment instead of the secondary levels.
            Of course, both these options were most likely available, and most likely without any data integrity constraints to force both fields to be identical, or at the very least not contradictory (which is a much bigger problem IMHO).
            Anyway, obviously not every smoker sported a formal ICD-9 and sometimes the social history just says Unremarkable, or if the patient doesn’t smoke, nobody bothered to click on that box.
            Sometimes maybe it was not recorded in either place, but noted in relation to something else maybe in the HPI or plan. In all cases the doc had the information he needed and all was well.
            Enter MU. All patients MUST have smoking status recorded, and it must use preordained categories for that. Obviously, your old comments next to the problem list are not satisfactory and neither is the free text. The social history is promising and may even be fine if and only if the EMR used the same categories as MU requires. Most did not.

            So what do we do? The simplest thing to do is leave it in Social and change the sub-levels to reflect the new mandated ones. This means one of two things: all existing data in the secondary levels will be deleted because the schema is changed, which is a big no-no of course, or we add a kludgy second MU smoking status with the approved verbiage and instruct doctors to stop using the old one (yikes). Another outcry is sure to materialize, because lots of users will be rightfully arguing that they don’t always open the social history section, and that’s a lot of work to do that for every patient.
            In addition, we still have to contend with the possibility of ICD-9s, so a new MU query would check the ICD-9, but be unable to obtain the sublevels, would then check the new kludge in social and come up with something that most likely won’t reflect the true status every time.
            We had to change the database schema, our database queries, possibly the template UI and we still have a significant subset of unhappy users and frankly a bad UI.
            So why don’t we postpone this for the next big release and for now just add a checkbox to the vitals screen, so the MA can capture this one and not bother the doctor at all? A workaround has been born, and I haven’t even talked about cessation advice.

            This is how sausage gets made in an EMR shop and you will be surprised to know that you are always the first concern for the little developer people, but their hands are tied when it comes to big overhauls…. Now if your CEO calls…. that’s another story.

          • MarylandMD

            Smoking status is a very important thing to note in every patient, and relevant to just about every specialty of medicine (that’s why it’s in MU!). It should have always been easy to document and a data element that was clearly shown so it was hard to miss when you even take a quick glance at the patient. If you buried it only in the traditional “social history” box 3 levels deep in your EMR UI, it shows you started out with a brain-damaged UI right from the get-go, and years before you could blame it on MU. So if you started out bad, you are unlikely to make it better just because MU came along.

            I never said adapting to MU was easy, but none of the challenges you bring out seem insurmountable. Making whatever you do with the smoking status logical and user-friendly may take a bit more time and creative thinking that a slapped on kluge. And if you care about the front-line user, you will make sure it happens.

            I’m still not buying it.

          • Michael Chen, MD

            MarylandMD,
            Your comment begs to ask a question that seems to have been inferred by other posters….”And if you care about the front-line user, you will make sure it happens.” Who is the currunt crop of large-vendor EMRs really catering to? The physician, the hospital administrator, the biller, third party payors? I would say that it is the latter 3. I recently posted on my blog that there was a quote from Dr. Mostashari (head of the ONC), “I sure hope that the EHR vendors are hearing the same levels of dissatisfaction from their customers and their prospective customers that I’m hearing. I hope vendors are focusing on user-centered design in the next iterations of their software instead of adding more bells and whistles.” And my response was there is no incentive for these EHR’s to focus efforts on user-centered design in the perspective of a physician because the physicians are NOT who they are catering to! First, it’s too much work for them (they want the easy way resulting in slapped on kluge, because there is no financial incentive to do so). Second, unless you are a solo doc who manages the finances of your clinic, the EMRs audience is really those who pay the bills.

            If you look at the historical progress of EMRs, most started out as pratice managment software. Some of them added a clinical component that made them into EMR’s today. But the backbone (database structures) of these systems are very much geared to capturing financial information, not clinical information.
            I agree, we need creativity to overcome these inertial forces that prevent doctors from getting a better UI experience…we deserve it. And not just for us, but for our patients. It sounds easy to do, but there are other forces at work here that are barriers, but physicians need to see them with eyes wide open.
            One overlooked (but huge) reason that is related to MU, but not directly, is the cost of certification of these EHR systems and how byzantine the process is (you have to recertify any new version of your system). It’s certainly not talked about by physicians unless you’ve tried to certify your own product (which I did) and which I decided was against the whole idea of innovation (for better UI, for example). So I intentionally did not pursue certification even though my project met all of the criteria. That is one major reason why UI design is on the backburner for most EHR vendors. These established vendors would have to pay an arm and a leg to change the UI and overhaul the system to recertify, pass the costs down to the purchasers (you or your clinic) and make their customers (hospital administrators, billers) unhappy. Guess who the EMR vendors are going to listen to?

    • David Do

      Thanks for your comments, Margalit. Can you give some examples of EMR companies that use those methods?

      Unfortunately, the dedication to agile methodology and usability doesn’t show, at least in the five EMRs that the majority of academic medical centers now use. While I agree that government regulations introduce inefficiency in a physician’s practice, there’s no regulatory obstacle to

      - displaying information in a clear, organized way
      - minimizing clicks for common tasks
      - clinical decision support

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Hi Dr. Do, the best way I can think of to independently verify that large EMR vendors use agile methodology and user centric UI/UX design is to go to a job board (e.g. indeed.com) and just randomly search for vendor names + any of the above terms that you are interested in.
        I know plenty of folks that are working or used to work iin EMR development, and agile/lean is the accepted methodology nowadays. This of course does not guarantee better software, or bi-weekly sprint releases for products of epic proportions :-)

        Regarding usability, let me just make a couple of points.
        First, a hospital EMR is by definition a huge beast, having to please many masters in a multitude of circumstances. All current EMRs evolved over many years of development, and even if you start from scratch today, it will take a decade most likely to bring to market a fully functional comprehensive hospital system. If you develop it in house, you only have to please the house. If you develop a commercial product, you have to please many houses, all very different, and this is the #1 reason why EMRs have 20 ways of doing every single thing. Multiply that by several thousand things to do and you have a usability and maintainability disaster on your hands.There is no good way to build consensus when your users are highly educated and fiercely autonomous users.

        Second, no matter how big your shop is, if every two years you have to expend significant effort to incorporate a host of useless (to the user) features, you will have less bandwidth for other things, and worse than that, you find yourself forced to cut corners to meet regulations.

        Let me give you a simple example: recording smoking status and smoking cessation advice. Before meaningful use, this was usually recorded in the social history section, and the intervention might have been recorded in the plan section, perhaps in free text or dictation. Now, to satisfy MU, these have to be structured data elements that are easily aggregated behind the scenes to produce the required MU report. The right way to do this would involve significant changes to both database schema and user interface. The “easy” way or the rushed way is to add a dropdown and a checkbox somewhere. Guess what most folks did? And here too, multiply by all MU requirements and here is your nightmare being born (and I am not even going into all the billing constraints that force you to click enough boxes to get the “optimal” level expected by your administrator. This should begin to explain the lack of clicks minimization, and the disorganized way of displaying information.

        Clinical decision support is a very thorny issue. What one person considers support, another considers useless alert or clutter at best. For example, I remember standing in a room full of pediatricians all excited about a pediatric dosing calculator that family docs really liked. The peds docs couldn’t care less because they dose stuff for kids all day long and the calculator is seemingly embedded in their head. Now MU2 is asking that the EMR be able to record and report that those pediatricians actually looked at CDS before administering an immunization. What do you think their reaction will be when they receive their MU2 upgraded EMR? Do you really think that there is even one respectable vendor out there that had a feature like this on their customer request list? Nope, and yet it will be implemented.

        Sorry for the lengthy reply, and don’t take this as an argument that EMRs are great. They are far from it, but the well intentioned government meddling is just making sure that they stay far from it.

        • MarylandMD

          You (and the EMR vendors) can drop phrases such as “agile/lean methodology” and “user centric UI/UX design,” but to the end-users (I am talking the front-line physicians, RNs, MAs, etc.) it all sounds like a bunch of silly nonsense when we have to stare all day at a screen that seems to be designed by a madman guzzling absinthe. Buttons in the upper left! Lower right! Upper right! Lower left! Unreadable fonts! Windows with menus and buttons inside windows with menus and buttons inside windows with menus and buttons! Important prompts in pale colors! Enter text and the buttons below move so you miss them when you try to click them! Sluggish response times! Uninterpretable warning messages!

          No, nothing “lean,” “agile” or “user-centric” about the Epic interface, that’s for sure.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            I actually have no use for any of those terms and I wrote critically about this over-hyped terminology multiple times in the past. I was just trying to answer Dr. Do’s question.

            I understand your frustration with Epic and I know many others that are as frustrated with a variety of products, and some to the point of quitting their positions.
            There are also those who seem to like the same exact products. Nothing is simple in health care, not even software, and I believe there are multiple factors compounding the problem.

          • MarylandMD

            Well, that seems to be a bit of a change. Initially you were blaming “overwhelming government regulations” as the reason for poor EMR software design. Now you admit it is “multiple factors.” I’ll consider that progress.

            Good doctors and staff are quitting and the EMR companies and their apologists blame government intrusion (this is an industry rife with government regulation for many decades–if they couldn’t handle it, why did the get in the business in the first place??) as the bad guy. Sorry, I’m still not buying it.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            No change at all. I am still blaming “overwhelming government regulations”. The compounding issue is that physicians decided to comply with those regulations, and decided to allow someone with conflicting interests to purchase the EMR on their behalf, and now are complaining that the seller is not catering to physicians needs.
            You know, when MU came out and even before that, during the CCHIT days of glory, there were several simple and elegant ambulatory EMR vendors that fought the “system” tooth and nail. They were defeated by their own satisfied customers. Some became “certified” and the rest went under. There is no market left for a physician centric EMR and in the hospital sector, there never was.

          • Georgia Newman

            I will again comment that eClinicalWorks is physician-centric and can be used in hospitals and SNFs. I have certified in 2011 and 2012 for MU. I am not a shill for ECW, just a satisfied internist user.

      • Georgia Newman

        Hi
        Just thought I would weigh in as an actually SATISFIED user of an EMR for 7 yrs–eClinicalWorks. This EMR seems to be designed for workflow, they have a new Scribe feature that can take undifferentiated dictated text from Dragon, and move it into discrete structured locations; they have a new version, eClincalTouch, designed specifically for the ipad.
        I am a primary care internist and geriatrician working in a solo practice with 1 nurse practitioner. the EMR is integrated with Dragon, so I dictate my extensive HPI, assessments and anyplace needing explicatiom. This, combined with macros, makes documentation of a level 4 and 5 visit easy and NOT the unreadable boilerplate junk I get sent by docs using EPIC: “the patient has had this problem for…, the problem has been …..” Whaaaa.?
        My problem? I am the only holdout in my area still solo–if I join the Mercy system, guess what I have to switch to? Epic without Dragon. Life is just too short

        Georgia Newman MD FACP

        • MarylandMD

          An island of sanity. More power to you.

      • Michael Chen, MD

        Hi David,
        I urge you to look at my open source EHR project, NOSH ChartingSystem (you can google it since KevinMD will sometimes reject the links). It’s aim is for all that you mentioned (minus the clinical decision support) regarding a modern, intuitiive user interface that is OS/Computer System agnostic since it is web-based system. It’s intentionally not MU certified because of the exact reasons I feel that MU certification hobbles and changes the user interface experience as well as being hostile to open-source (extreme cost of certification for new versions, which happen all the time in open source projects like mine).

        • http://symcat.com/ David Do, MD

          Michael,

          Thanks for sharing. I think this project is a good start, although any solution needs to be developed alongside the users. Does/will your EMR have an API?

          • Michael Chen, MD

            I totally agree..that is why I developed my project as open source, to encourage feedback and improvements directed by the users (the medical providers) and not based on what I think alone (even though I developed it initally based on my own practice workflows). In terms of API, I plan on making my system more customizable from a DIY perspective (creating own templates but that you don’t have to be a computer programmer to know how to do it). If any provider or health IT person that is working with a provider knows how to program with php or jQuery, there are APIs for both that will allow anyone to customize the system to their heart’s content. The database structures are, I believe, straightforward if anyone sees the code, so from and API standpoint, there is a future for that. I’ll be doing a crowdsourcing campaign fairly soon through Medstartr which hope will bring more awareness and visibility to my project.

    • MarylandMD

      After using both Centricity and Epic, I am just not buying it. Many of the things that I find objectionable about Epic in particular have nothing to do with “overwhelming government regulations” and have a lot to do with poor user interface design that looks more like software designed in the 1990s. Say what you want about how much Epic may “care,” I have never worked with software that is so universally reviled by the front-line users as Epic. Epic’s real “client” is not the poor sap who has to use it every day, it is the cloistered administrator who rarely if ever has to click a mouse on anything other than PowerPoint presentations or Excel spreadsheets. I am sure Epic cares about the suits. But the MAs and the physicians? Nope.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        I don’t know who Epic cares about, but I do know that users have voted it #1 in KLAS surveys for large practices. Why is that?

        Speaking of 1990 UI, VistA, which I have yet to hear a physician complain about, has a user interface that looks like something from the stone age, and popup on top of ugly popup until you have no idea what you are working on. So why do users like it so much? Could it maybe have something to do with billing needs not being so important at the VA?

        I do agree with you that EMR vendors cater to those that make purchasing decisions and write the check. You can build the prettiest rosebud out there, but if nobody is willing to buy your product, you have no product and no company. So maybe the anger and frustration is somewhat misdirected…

        Furthermore, even in the ambulatory private sector, physicians complain about usability, yet nobody will purchase an EMR that doesn’t do billing exceedingly well and is not MU certified. If we are after pure usability, why are we demanding other features first and foremost?
        It’s like insisting that your car seats 7 and a dog and a few road bikes, and then complaining that its aerodynamics are so much clunkier than a Corvette…

        Even if you think that EMR vendors are a bunch of unscrupulous used cars salesmen, and many are, they will still act like all self preserving sellers in any free market and manufacture and sell what the market demands. Problem here is that the market is rigged and the unprecedented demand for clunky products generated by MU, and the hospital and ambulatory powers to be willingness to comply with it, is just reinforcing a bad situation. So instead of advancing from “really bad” to rather nice, as products usually do, it is now “slightly more really bad”.

        • MarylandMD

          I just went to the KLAS website and the first thing I see is “rate your vendor.” Yeah, that sure is a scientific survey. I’ll be sure to give that a lot of weight. KLAS looks more like an organization for suits who buy, but never use, EMR software.

          I have a hard time believing EMR industry PR about how users “like” their interface. They “like” it compared to what? A rectal exam? A sharp stick in the eye? Digging a ditch? Painting a garage?

          I start thinking “Stockholm Syndrome” when I see these surveys. Most users don’t know one thing about any of the alternatives; they are trapped with the EMR and cannot escape. They come to terms with the software, but if you take them out, give them a beer or two and talk with them for a while, they’ll start telling you all the things they hate about it.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Which puts you in the same boat with all other folks that have to work for a living and use software in the process. People hate Outlook and salesforce and SAP and whatever garbage interfaces bank tellers are using, etc. etc.

            People like recreational software, which was built to keep them happy enough to overlook the fact that they are being conned into buying things they don’t need while donating their personal information to those who want to sell them more things they don’t need.

          • David Do

            Is there a fundamental difference between software for work and “recreational software”? Gmail and Mailbox are some of my favorite workflow tools. Many people benefit from the productivity of their iphones and androids.

            Yes, people like to groan about Microsoft’s tools, but the dissatisfaction in the hospital reaches a new level. Physicians would often prefer to manage their patient list on a Word document than the EMR.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            There are several fundamental differences: magnitude, complexity, frequency and duration of use, and integration are some of the most important ones.
            Software like Gmail and Mailbox, do one thing and one thing only, so those who develop it don’t need to compromise anything in this one functionality to accommodate a hundred other equally important functions.
            The task itself is easily conceptualized and understood by most people and has very few corollaries and divergent paths that need to be accounted for.
            These are not “heads down” eight hours a day products. They are used willingly, by a single user (no concurrency problems), in short bursts (usually) and/or infrequently, which means there is no fatigue factor to deal with.
            Also, how efficient are they really? How long did it use to take people to go through their mail say 20 years ago? Have we gained much “productivity” from checking email every 5 minutes?
            Finally, products like Mailbox or other cute little apps need not consider the world around them. They cannot accept information of all kinds from business partners and/or integrate with say SharePoint which may be used by the institution you work for, and you as a user have no expectation that they should.
            EMRs on the other hand, are expected to cover the full spectrum of hospital operations in a “seamless” and efficient way that pleases all types of users all the time. It’s a big difference.

          • http://symcat.com/ David Do, MD

            Margalit, i challenge you to spend some time in a hospital, where you will quickly discover that there are usually ten systems that each do one thing, and often do it poorly.

            “EHR vendors propagate the myth that health IT is qualitatively different from industrial and consumer products in order to protect their prices and market share and block new entrants. In reality, diverse functionality needn’t reside within single EHR systems, and there’s a clear path toward better, safer, cheaper, and nimbler tools for managing health care’s complex tasks.”

            -Mandl and Kohane, NEJM 2012

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Yes, and 3 years ago Drs. Mandl and Kohane convinced ONC to award them a $15 million taxpayers’ grant to develop an open EMR platform for substitutable apps (like the iPhone). You would think that there should be some ground breaking EMR in existence by now, no? There isn’t. There are a few very colorful apps to display growth charts, blood pressure, a Reynolds risk score and a maybe a few more peripheral things. There is no “clear path” towards anything substantial and there are no short cuts and hospital EMRs are not like an iPhone. Never will be.
            Hospitals are billions of dollars businesses. People that want to penetrate this market need to understand that, accept it instead of invent a parallel reality, and produce the capital needed to support construction of products that can manage the business of multibillion dollars corporations.

          • MarylandMD

            So the EMR vendors console themselves with their terrible UIs by saying “Well, SAP is at least as bad!” It just sounds like we are rationalizing their inadequacies. So they think they can’t do better and give up?

            While I am not in love with Outlook, I would trade it’s UI for the nightmare UI in Epic any day of the week.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            I know you are angry and I am not faulting you for that, because the products you are being forced to use are made to order for someone that doesn’t care about you at all – your employer.

            I am also going to go out on a limb here (and try kevin’s new image uploading) and say that it’s really not the Web 2.0 aesthetics of the UI that are the problem. Below is a typical screen shot of the most beloved EMR – VistA. Let’s put aside the arguments regarding EMR vendors’ ethics or lack thereof, and try to figure out why this older than Old Yeller program, built on the same infrastructure as Epic, is considered so good. Ideas?

          • MarylandMD

            Why, yes, I do have a few ideas. Thank you for asking.

            Now, I would have to live with the software for a few hours (preferably a few days) to give you a good answer, but here are a few things that I think I see based on this very limited view:

            –Nonmodal. It appears in VistA you can have multiple windows open and do several things at once, flip between windows, move them around the screen, etc. This is very good. Centricity: very modal (very bad). Epic: better than Centricity, but still fairly modal (pretty bad).

            –Colors. The designers didn’t go crazy with colors. Colors, unless used in a judicious way, can be very distracting and lead to eye and brain strain. The VistA screen looks a bit boring, but boring is often good. Centricity: limited use of colors (good). Epic: too many colors, and they are poorly used (very bad).

            –Standard UI Elements. VistA seems to use standard pulldown menus in a menubar across the top of the screen. Buttons are simple and laid out in an organized fashion; the buttons seem to line up across the top left or the bottom left of the screen. People are used to these elements and these arrangements from the many Windows and Mac programs. Figuring out targets is relatively easy. Centricity: standard elements, mostly (almost good). Epic: very nonstandard buttons, tabs, and menus, some behaving in unusual ways–some menus pop UP from the bottom of the screen! Buttons EVERYwhere! (very bad).

            That is what I see so far. Note that all the items I am talking about have **absolutely NOTHING** to do with MU, CPT, ICD-9/-10, P4P, HIPAA, EIEIO or any other set of letters you so badly want to blame for the poor choices made in basic UI structure and design by Centricity and Epic.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Actually those popups are very modal indeed. It takes three layers of popups to record one set of vitals. You can move them around though.

            Anyway, this is a much better discussion now :-) because I understand that you are bothered by the actual appearance of the software, and perhaps not so much by the sequence of tasks that must be completed. That’s fine, and you are not alone. I actually heard some docs refer to this or that product as “dull” because of the ubiquitous grey of windows forms. A little bit of color can indeed spruce things up…. Many other folks though are bothered more by all the stuff they need to do in there that in their opinion is not contributing anything to patient care. The latter is what all those acronyms brought us.
            Please understand that I am not in any way defending Epic or Centricity or any other mega-corporation (they don’t need my advocacy anyway). I am trying to explain why things are not getting fixed for you, and are actually getting incrementally worse. Once upon a time the EMR that Dr. Newman is raving about was considered buggy and convoluted. Many products (all?) start out that way and are then incrementally improved based on clients’ feedback and based on the sales department asks for.

            It’s not incompetence, carelessness or some other conspiracy. It’s prioritization, and it’s very much like medical triage. If you don’t do MU first, you die. If you don’t do what the hospital CEO wants, you die. If you don’t do what this or that doctor asks for, you are hurting.
            VistA developers had no such limitations.

          • MarylandMD

            No, I am also bothered by sequence, number of clicks, lack of keyboard shortcuts, logical flow, consistency across different modes, and a whole lot of other things. You showed me a screenshot and I responded to what little I could see. But the superficial appearance is very important. Things like eye strain and fatigue can make even good software a chore to use.

            You must know that when you said “a little color can indeed spruce things up” it really made me cringe. I am sure the programmers at Epic thought they were “sprucing things up” when the added their irritating colors. Keep it simple. Use color very gingerly. Please, pity the end user who has to look at those awful colors for years and years.

            When a medical system pays hundreds of millions of dollars (you read that right–we’re talking over half a BILLION dollars) for an EMR, I have a very very hard time believing they just don’t have the resources to fix their awful interface, no matter what MU requires.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            That’s OK. I don’t think that anything anyone can say will change your opinion at this point. Note that I was not trying to convince you that your EMR is not as bad as you think, but tried to explain why it is so. If you are even mildly inclined to give this explanation the benefit of the doubt, it may provide you an actionable venue to affect change.
            Hoping that some other “innovative” iPhone/iPad “open” product will soon rise and replace the “evil empire” is not a pragmatic strategy. Aggregating and exerting coordinated influence on your existing product is much more likely to provide some relief (e.g. get all your doctors together, pick 3 concrete things you want fixed in the next quarter and have your CEO call the vendor and raise hell, repeat every quarter).

  • Edward Stevenson

    Great article. As a medical student I was interesting in getting involved in EMR development seeing how poorly EMR were designed on my rotations. I contacted over 20 prominent EMR companies large and small volunteering to be part of their design team with-wire sketches in hand. The response was a resounding no, no, and no thanks, “we already have one or several physicians who work with our design…but would you like to buy our system.”. I investigated who some of these design consulting physicians were to find that the majority were trained in computer programing in the 70′s and 80′s holding their accolades in programing in MS-DOS, and early windows based systems. It was no wonder why all the leading EMRs look and feel like a flash back to 1995.

    The other half of the story is that documentation (paper and electronic) is a billing and legal instrument not a document for patient support. As long as we are using a health finance system build by the people who brought us tax forms and tax code we are going to have EMRs that are as fun to use as doing taxes. When an organization wants to use documentation principally for patient support and billing second we will see innovation.

    • David Do

      Edward, you’re absolutely right. Building a usable EMR is not simply for the convenience of the doctor. It has tremendous implications on patient safety by integrating information in a more effective way (allowing monitoring for SIRS or other conditions), facilitating communication between providers, and eliminating duplicate tests.

  • Ron Smith

    This is so much what I’ve been talking about with our staff. I developed my own practice management EMR (besides being a Pediatrician, I’m a professional database programmer by default). Usability is important but time savings is critical.

    For example, I designed a method for my practice manager to go to our claims processor online and within 15 seconds process EOBs so that all patient payments and accounts were updated. For her this is invaluable.

    Every feature of our EMR is meant to save time, improve accuracy, and assist us in providing the best care.

    Meaningful use in my opinion is simply medicine on welfare. Those who accept have put the government ring in their own noses.

    That one EOB feature I mentioned saves our office about $75,000 YEARLY in staff expenses that would otherwise be required to process that data. Meaningful use reimbursements pale in comparison with just that one time-saving feature. There are many, many more in our solution.

    Ron Smith, MD
    www (dot) papercutpro (dot) com
    www (dot) ronsmithmd (dot) com

    • http://symcat.com/ David Do, MD

      Ron, thanks for sharing. I am a big fan of homegrown solutions, because they are built out of necessity with the workflow in mind. At the same time, it’s a shame that there are so few good solutions that you have to reinvent the wheel, and that you’ll be punished for trying to solve the problem yourself.

      • Ron Smith

        My solution was deployed in 2000 and not as a result of current national changes in healthcare. We were trying to solve a problem of efficiency. In Georgia, there are strict vaccine documentation requirements. Every daycare or school must keep on file the official form 3231 vaccination form. Each of these forms must be created from top to bottom. You can’t photo copy an old one and add the new information each time you vaccinated a child. It had to be rewritten by hand every time in toto. Each form 3231 would take a nurse from 5 to 7 minutes to complete.

        We solved this efficiency problem first with my software. Since then it has networked three offices in real time and provided emr data services for up to 33,000 patient visits a year…all running on one server connecting the three offices with a T1 speed connection.

        Development is ongoing. Because I’m using this in my current practice, the development of a superior solution occurs because it meets real needs. Because I’m a practicing Pediatrician, I’m the software’s biggest critic. When something doesn’t work right, then I work out a better solution.

        We consider every possible new feature. I added RS 232 interface integration and now my CBC and UA machines are connected so that the nurses only have to enter the patient id number then insert the test samples. Results are automatically entered into the patient record.

        Patients can purchase a PediKey which is a a flash drive in an aluminum waterproof capsule into the kiosk computer in the foyer and download all their childrens’ medical records in PDF format directly from the server. The cost is $15 one time for them to carry the entire medical record in their purse of pocket and they can update the records anytime by inserting their PediKey into the Kiosk. PDF can be read by every modern computer in the world.

        Our development is lead not by profit but by my and my office staff’s need for not just cutting edge, but bleeding edge, technology.

        This technology allows me to manage patients and their care practically anywhere. It gives me the ability to do solo practice without having to share call with another physician.

        Phooee on ‘meaningful use’ and whatever that really means. Give me state of the art and beyond or let me retire!

    • Fred Ickenham

      For all the above reasons, our Neurology practice has avoided buying EMR, in favor digital dictations sent out to referrers and third parties. One day though, we’ll probably have to use an EMR. Would your user-friendly EMR be adaptable to such a practice as ours? Your website does state about the same as the excellent article above by Dr.Do. However, interoperability concerns, and the likely need to associate with one or more ACOs may force us to adopt Allscripts or similar widely used program.

      • Ron Smith

        Our software is based on the history and physical which we all know well. it is adaptable to almost any primary care and specialty because we have customizable fill templates and choice lists.

        The questions that you need to ask vendors about their software is:

        1. How was their software developed? What physician input was there?

        2. Besides the EMR recording part, does it help structure an office to be the most efficient. Even great EMRs won’t make you money, but if designed correctly they should help you stop wasting money that you are throwing away now.

        What is worth talking about it the ability to connect with HCEs, or health care exchanges. A health care exchange is what will be the glue that links all end user software together.

        We are part of a group here in Georgia that is presently working on linking all the major hospitals and providers through an HCE network.

        You only need to be part of any one HCE as there will also be a network of connections HCEs one to another. In other words the HCE will be like a realtime data convertor and each EMR will interact with the HCE, and maintain their individuality and functionality.

        Because this is coming down the pike I’m not focusing yet on local interactions with specific other EMRS or hospitals which will be proprietary. Each individual interactive relationship would require rewriting and extensions that are costly and perhaps not even doable.

        The HCE concept is lean because it will establish a data standard of transmission which is not file based. In other words, you won’t have to worry about which version of HL7 you are connecting with because we will be interfacing computer to computer in realtime similarly to the way we interact with a web page.

        Hope that helps!

        Ron Smith, MD
        ron (at) ronsmithmd (dot) com

  • BrianMc

    Great topic. i think it’s important to remember that the systems be called out here are old. They use old data management technology (mumps) and in the case of Epic the core system moved from Veterinary to human in the early 90′s which is why it looks and feels antiquated.

    My feeling is that we could have used our government incentives to force more openness and innovation- demand standards. The current push is to create electronic versions of current workflows and a few billionaires along the way. The proprietary nature of these systems then surpress innovative solutions that can improve those workflows.

    • http://symcat.com/ David Do, MD

      I would agree that openness is one of the keys to improvement. That will allow innovation to take place within the walls of the hospital. Sure, these EMRs are running on older frameworks and data structures, but that doesn’t mean the interfaces should be antiquated too.

      • BrianMc

        The top EMR vendors will resist opening up the interfaces. Glenn Tullman tried that at Allscripts when he moved his development organization to Agile and opened up up to more modern interfaces. Wall Street punished him and it ultimately cost him his job.

  • azmd

    Honestly, at the risk of sounding cynical, I have to say that another factor impeding the development of user-friendly EMR systems which would do a better job of supporting clinical care is this: what incentive does the hospital have to insist that?

    From the facility’s standpoint, as long as the EMR supports efficient coding/billing functions and regulatory compliance, the cost in terms of lost physician efficiency and adverse effects on clinical care is just not compelling enough to drive a demand for improvement in the system.

    • http://symcat.com/ David Do, MD

      You’re absolutely right. There has been very little incentive for hospitals to demand good technological solutions. They need to realize that there are benefits for patient safety and cost-savings, and that they are overpaying for poor implementations.

  • Allison Falin

    Prior to becoming an FNP, I was a data manager for 6 years (prior to that CCU nurse) and also worked on McKesson EMR development with our health system. Far and away, the largest issue we ran into in the hospital setting were the following:
    1. Lack of compliance with going paperless (nurses were bad, but physicians were worse about complaining here).
    2. Lack of flexibility within the McKesson system to actually create a record that made sense clinically and flowed with the daily work done.
    3. Physician groups that bought software in their offices and expected interfacing to occur to the health system (interfaces ran anywhere from $25,000 and up). They were not pleased to find out that the costs were quite prohibitive. It gave them a lot more fuel to the fire.
    4. Physicans that pushed the CFO at the hospital into buying new products (such as OR anesthesia monitoring) and other products that were not McKesson compatible.

    I watched hundreds of thousands of dollars go to waste in unused or underutilized software just in 2 hospitals alone. I cannot imagine the amount of financial impact that would have on a hospitals bottom line capital budget.

    The reason that we never consulted medical residents on our builds was due to the fact that they left after a short period to time to go to different facilities. We did have super users that were ER providers, nurses from every specialty and some other sub specialty providers (cardiology, oncology, peds).

    • azmd

      I am puzzled by what is meant by “lack of compliance” in your comment. If a health system adopts an EMR, then providers within that system are forced to use it. How exactly would a provider not “comply?”

      • Allison Falin

        The initial roll out was to the RN staff for 4 years I think it was (I left while this was going on), but I know that I was there working in 2005 and it wasn’t until 2010 that they rolled out POE (Physician Order Entry) due to a HUGE backlash of the Chief Medical officer and other influential MDs at the hospital. At the time, we had minimal buy in, still do, and the resistance to change was (and I hear it still is) quite difficult.
        I think you will always have early adopters and naysayers, but aside from charge CCU nurse, this was easily the most stressful job I ever had.
        A lot of it, I think, had to do with McKesson’s platform. It was clumsy and difficult to use; not user friend at all. I have worked with 4 MDs and a NP while doing rotations in school and they all used AllScripts, which was far more user friendly. Only 1 MD hated it and he had his office nurses inputting data for him after he wrote it on the old routers and in the chart. The others seemed comfortable with it and even embraced it. I think he will come around at some point, but for now, not so much.

        • azmd

          OK, I guess I would have a problem with using the term “noncompliant” in referring to clinicians who are objecting to the adoption of a system that is admittedly “clumsy and difficult to use.”

          Rather than branding those clinicians as “non-compliant,” perhaps their concerns should have been given serious consideration by the healthcare system.

          • Allison Falin

            It is being non-compliant when you refuse to do what the health system that you hold privileges at adopts as an EMR for 2 major trauma centers, 6 outlying rural medical centers and multiple MD offices. You cannot run a large health system IT department with every provider office running their own specialized EMR. It all has to interface in and to do that in a cost effective manner, you go with a package deal. Allscripts has its quirks, but it is an improvement. Funny enough, about 2 years after I left, the system replaced all the Clin. Apps folks with McKesson contractors to “right the issues” believing that it was a roll out issue.
            Cut to now and they are finishing up the process of adopting an entirely new EMR for the entire health system. They spent MILLIONS adopting in a system that did not work and wasted valuable resources that could have been used to offset patient costs, bring in innovative solutions to ED workflow, and other capital expenditures. That was the point of the post. It was not to brand people as being horrid for their non-compliance. You can be a good provider and be non-compliant. The decisions were made by the CEO, an ER physician himself, that was brought in by the board of directors (also having MDs on that as well).
            There were other issues within the health system that have nothing to do with IT, but like most facilities now, they are laying off administrators and culling the herd on staff to cut costs.

  • HealthyTJ

    Good article.

  • http://symcat.com/ David Do, MD

    Dr. K,

    Unfortunately, EMR programs are hard for those of us who grew up in the internet age as well. It’s okay for doctors to say that these EMRs are obtrusive, and demand that they be designed around workflow.

    • John Pearson, MD

      Seconded. When you have over 10 logins to over a dozen systems, plus paper at the same time, it just becomes a giant time suck. I spend more of my day as a resident trying to find usable data than seeing patients. Seriously. And I worked in information systems for several years prior to my career in medicine. It’s completely absurd. The worst part is (this article being an exception) most people involved in discussing, implementing and purchasing EMR systems have NO CLUE AT ALL about clinical medicine. If they just spent 1 week shadowing residents they would understand how dangerous the situation is.

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