Like Topsy

If William F. Bria, MD, had his way, EHR design and engineering would begin again from scratch, taking into account not only "requests and desires, but actually the needs of the end customers."

"And, by that," he says, "I mean the doctors, the nurses and  -  more and more these days  -  the patients. A redesign of these systems and a more consistent model of their use would greatly benefit the industry."

Bria is CMIO of Shriners Hospitals for Children, with 20 hospitals across the country  -  and one each in Canada and Mexico. 

Shriners EHR: Cerner.

"The EMRs are such a trial and travesty it's not funny," he says. He rates Shriners EHR as "about the same as its competitors."  

Cerner is at the top in market share today, followed closely by Epic, at No. 2. 

"Cerner and Epic, and really most of them, are products that have been created incrementally over time" Bria says, "for very good reasons  -  business compliance, you know, just opportunity. The reality is these systems were created not all the same design, not the same moment, not the same way."

As a result, users are presented with a jumble of choices  -  dictates, really.

Bria describes it this way: "The idea of when you close, and you've got to work with this screen, for this particular problem, you click on the upper right. When you do it in this other part of the system, it's on the upper left.  When you use another part of the system, what you need is in the right lower corner. 

"If it was only that frustrating or difficult, it would be great," Bria says. "But unfortunately as these vendors have had to respond to the marketplace, and because of the lack of standardization in healthcare, these systems grow like Topsy - they get bigger and bigger and bigger, until no one can understand how it started."

Foley, the user-experience expert, likely would understand Bria's frustration with the changing, growing and gangly systems.  

Her father was a graphical designer and an industrial designer, who taught her and her seven siblings, about colors, typefaces and design. She learned about elegance at an early age. Less is more.

"We were just steeped in this design culture," she says. "We couldn't walk past a chair without him asking for an impromptu analysis."

She was captivated by all of it, and increasingly, for her it became about software design. She got her start in the '80s, working on installed software at a time when everyone knew the F1 key was the "help" key. But, she knew there was much more to software design.

"This is all about human psychology, perception, cognition what we make of what we perceive and how we decide to act on it, is far more complicated than just a list of function keys and keyboard shortcuts and where the scroll bars will be laid out," she figured then. "And, as it turned out, that's, of course, the case," she says.

She describes the healthcare sector as "sort of the land that time forgot in terms of human factors." Industrial design is working well, she says, so the hardware is fine, but the software  -  especially electronic health records  -  "has had a tough time."  

As she sees it, one of the major problems with software design is trying to replicate paper processes in a digital format.

"You know, scribbles in a paper chart might not be the best way to make sure you found a drug-drug interaction," she says. "But nonetheless there were a lot of benefits with the paper system. So when people came along and said, 'let's get electronic,' I think there was this sense of 'let's not throw the baby out with the bath water.'

"So, we'll take the current system we have, which in some ways in terms of its efficiency, works reasonably well. Let's just translate that over  -  translate the paper directly into a digital environment."

When taking something that's been bricks and mortar, or paper and pen, and trying to recreate it directly into a digital format, "you will lose the benefits of the bricks and mortar and the pencils and paper  -  and you probably will not get the benefits of the digital. You need to invent something new to solve the same old problems  -  something new that takes advantage of the digital space." 

Otherwise, the result could be what Bria describes as "a situation where the steering wheel may be on the left side, could be on the right side, could be under the dashboard. Or it could be a joystick instead of a steering wheel."

"It's only a little hyperbole I used," he says. "It's pretty much like that."

Foley also warns against customizations masquerading as a human-centered design. Beware of the physician who says, "I know I will love this if it just does this instead," she says.

"Maybe you will have removed something you hate, but that doesn't mean that customization will give you something you love," Foley suggests. "I'm always interested in people telling me what they think they want, but I always make sure that we watch them using, doing their work so that I can figure out what they might be missing or how they judge success and what motivates them when they use a particular system. That's especially true when you have more than one person using the system."

Data entry

The single biggest usability problem in EHRs today, says Foley, is that doctors have been turned into data- entry clerks. 

EHRs should be a tool, she says. "We shouldn't be in the middle of it saying 'you forgot to fill out this field in exactly the way, I, the digital tool, expect you to do it.'"

Not only do doctors become frustrated with their data-entry chores, they also become numb to what's put in front of them, Foley contends. "

"A doctor who is seeing 15,18 hypertensives in one day and has waded through all these form fields and drag downs and pop ups and so on, they get numb," she says. "This is not failing for any individual person. There are limitations on human memory. There are limitations on the ability of a human being to look at a screen full of pixels firing and find the couple of pixels that are different or unexpected."

Today, meaningful use is driving EHR uptake as never before. As a long-time advocate for health information technology, Bria has been waiting for this for a long time. It turns out to be bittersweet.

"The fact that medicine is taking seriously what a lot of us thought in the 1980s and earlier, if it were adopted, would improve the safety and the quality of care, is wonderful, he says. "And, so this is our rapid growth phase, and it's a mixture. It's like watching your kids finally graduate from college, you know. It's great. However, it ends up being a combination of pride and pain."