Jiajie Zhang

Co-director, National Center for Cognitive Informatics and Decision Making in Healthcare at the University of Texas Health Science Center at Houston

Associate dean for research, professor, UT Health School of Biomedical Informatics

Principal investigator, ONC’s SHARP program for patient-centered cognitive support

In your research so far, what have you found to be the most challenging – the toughest nut to crack?
The toughest nut to crack for us is to get the EHR vendors to work on their products’ usability systematically. Only a small number of EHR vendors have their in-house team doing EHR usability. Most EHR vendors do not do that systematically. They may do that informally here and there, but have not spent effort to do that systematically.

So usability has not normally been part of their routine in terms of developing their products?
Some EHR vendors think that usability is common sense, and that everybody can do it. They don’t realize that it is a profession – just like an architect. It needs to be done systematically and by professionals, of course, who are doing this as their job. Other vendors simply dismiss it altogether and have the impression that it is subjective, not scientific and not useful. For other vendors, they do want to do it, but they do not have the budget to do it. From our perspective we know that what we do here is to view usability as a science. Actually, it is a scientific field built on many years of research and practice in many other fields. The toughest task for us is to convince the vendors to do it. This is especially good timing because, for the Stage 2 meaningful use, usability may be part of the certification. If this happens, it will give vendors more incentive to do it now.

How much of your research involves talking with physicians on what works for them and what doesn’t?
We work with them almost every day, and that’s part of the method to do things right because you have to work with the real users. We work with them in different ways. We observe them in a real clinical setting like the ED, the practice site, ICU and other places. We do interviews. We do surveys. And also, we bring them to our lab to do testing. What we are hearing now is that they do not like the data entry part of EHR. Almost all of them are saying the entry slows them down dramatically and makes their task less productive. Others are concerned about patient safety, making errors here or there. On the other hand, they all like the information retrieval part. They can get documents and data for their patients at their fingertips. So that’s a big upside.

Based on your work to date, what part of the EHR design is most lacking?
The most lacking aspect is a user-centered design. Let me use a metaphor: If you have used both the DOS system and Windows for PCs, and you know the differences between the two in terms of usability, you know the DOS system is a command language. It requires a lot of memorization and learning. On the other hand, Windows is much easier to use and to learn. It is intuitive. It is designed for average users who may never take a course in computer design. Many of today’s EHR products are still in the DOS age in terms of usability. The good news is we know how to transform an EHR. It is a task that should be done systematically. We have the funding to help the vendors make the transition smoothly. If the vendors allocated the required resources, it can be done in a matter of a few months.

How much of your research is focused on clinical decision support, and might your research lead to greater uptake of CDS?
We have two projects that have a focus on clinical decision support. Our focus here is to look at clinical decision support systems from the user’s perspective. So we have to know what users do in their decision-making process before you can design a system for them to use.

One of the barriers to the uptake of EHRs is the cost. Might the cost go down if usability goes up? Or not?
The cost of the EHR for small practice providers is partially offset by federal incentives. If the usability of EHR systems goes up, the price may actually go up because it has competitive advantage. They can charge a premium. Consider the iPhone has much better usability than some other devices, so they can charge a premium.

You are still in the first year of your four-year research. Any surprises so far?
The biggest surprise is the usability gap between the status quo and what can be done for EHRs. Initially we knew that the gap was big. However, the extent of the gap did surprise me. For example, in one small demonstration project as part of my usability class, the students redesigned a model of an EHR and improved its usability dramatically. For one meaningful use case, the number of staff required to accomplish the task was actually reduced from 91 staff members to 14, and the time was reduced from about 100 seconds to 10 seconds. That’s the kind of improvement you can make.

Bernie Monegain interview