Beauty, they say, is in the eye of the beholder. What about usability when it comes to machines and especially software? Is the ease with which software displays and moves, how nimble, how flexible the program is or is not  -  is that, too, a matter of subjectivity, in the eye of the operator? Or is it more a matter of design and engineering?  Is it unreasonable to expect elegance?

These are all questions bubbling in the healthcare IT cauldron as physicians grapple with a love-hate relationship with their electronic health record systems. One minute they find their EHRs exasperating, the next, they give digital systems credit for saving them  -  and their patients  -  from the chaos of paper charts and manila folders.

"EHRs are not bad at everything," asserts Jiajie Zhang, director of the government's SHARP program, which is looking into all matters connected to EHR usability. Zhang also serves as interim dean, University of Texas School of Biomedical Informatics at Houston.

"If you ask a provider/user, 'if you have a chance to go back to paper are you going to do it?' Most of them said not, Zhang says. 'I hate it, but I love it.'  They expect more because their experience with other electronic products like the iPhone and other things is much better. So they expect more from EHR vendors."

Usability gets attention

EHR usability was top of mind with the Office of the National Coordinator for Health Information Technology (ONC) as it hatched its plan for projects in support of the meaningful use incentive program. The Strategic Health IT Research Projects (SHARP)  -  there are four  -  all of them established, in the words of the ONC, to "address well-documented problems that impede the adoption of health IT.

One of the four projects, the one headed by Zhang, is focused on usability, workflow and cognitive support issues. It addresses work-centered design, cognitive foundations for clinical decision-making, adaptive clinical support, clinical summarization and visualization and information design.

With the release of the final certification rules for meaningful use Stage 2 on September 4, the ONC took usability beyond research and required usability testing to attain EHR certification.

Zhang views the rule as "game-changing.

"We as well as many other stakeholders have been pushing very hard to make EHR usability as a requirement for meaningful use," says Zhang "We tried to get it in Stage 1. It did not happen. Finally, we're glad that it's now part of Stage 2."

SHARP is developing guidelines, a toolkit and software to help vendors improve EHR usability faster and more efficiently.

To attain certification for their EHRs, the vendors will have to demonstrate they have used a user-centered process to evaluate their product and report the results in a specific template. The vendors have to show all eight meaningful use cases enumerated in the final rule have been through some kind usability testing.

"It's pretty straightforward" Zhang says. "It's process oriented. You simply have to show that you used this process to conduct your evaluation and you have some results.

Process is key

Mary Kate Foley, vice president of user experience for EHR company athenahealth, says process is the way to start.

"The process is very, very important," she says. "I like the fact that the ONC went for process before content or standards. I was actually worried they would try to freeze EHR standards as they are today. I think EHR standards are not good enough to be frozen into a government regulation just yet."

athenahealth tests more than the eight measures required for usability testing under the rule, Foley says. "But focusing on the eight is great because it's going to take a little while for the certifying bodies to understand usability. I think we should all expect some discovery along the way."

Rosemarie Nelson, principal of MGMA Healthcare Consulting Group, agrees process is key, but she's not sure certification is the way to go. She advises physicians on their EHRs day in and day out.

"Sometimes users rant about their software without ever looking at their processes," she says. "For the most part, those people who are kind of like the silent majority, kind of like the voting public, they aren't complaining about that. They do struggle with reworking their workflow and process. But it isn't, in general, the kind of thing that they feel is clumsy. Usability really is in the fingers of the user. I'm not sure certification is going to improve it. I think the market is the final test of usability.

The testing requirement worries Mark Segal, vice president of government and industry affairs at GE Healthcare IT.

"We're very strong supporters of good user design and user interface, but there's a concern that, for the short time available, having to go back and basically make sure that formal user-centered design principles were applied to the specified functionality is a challenge in a short time period, and for software that's been already developed and out in the market for some time."

The time challenge can't be understated, said Segal. "We are just a little over a year away from when hospitals, for example, will need to be using the certified product."

In Zhang's view, the time is now.

"The bottom-line message is that most systems can be dramatically improved," he says. "So meaningful use Stage 2 is kind of a stick for the vendor. You basically have to do it. If something can be done, it's time to do it. It's not trivial, but if you cannot do that, all kinds of consequences can occur  -  like safety issues, which is the biggest concern."

Also, as Zhang sees it, for the long term, if a vendor's product is not competitive in terms of its usability, it won't be competitive in the market.

Usability is becoming increasingly valuable in the marketplace, he says, noting that Apple, known for its easy to use products, eclipsed Exxon Mobile last year in market cap. Ergo, "usability is more valuable than oil," he says. "That's what EHR vendors should do because eventually usability will have a huge impact on their market share."

ONC chief Farzad Mostashari, MD, also referred to an Apple product in an interview last year with Mary Mosquera and Tom Sullivan, editors at Government Health IT. He talked about his predecessor David Blumenthal, MD, who used to say that his dream was for providers to be excited to boot up their EHR when they come to work the way that you enjoy, say, lighting up your iPad. 

"It's not true that doctors are late adopters of technology," Mostashari said. "I saw some incredible statistics around iPad and smartphone adoption by physicians. It's clear that the provider community and from the research that improving the usability of systems is an important goal. The question is how do we do it?"

Robert Tennant, senior policy advisor for the Medical Group Management Association (MGMA), says it's about time usability becomes part of certification.

"We've been pushing the idea of usability for a long time," says Tennant, who was involved in the formation of CCHIT, the first EHR certification body, and today one of six authorized by the government.

"In the early days of CCHIT I kept saying you know it's not good enough just to test functionality. If it takes a thousand keystrokes to get to something, well, it is not very user-friendly."

The pushback, he says, came from two sides: CCHIT and the vendors. 

"The vendors themselves were leery about including usability in the testing criteria," Tennant says, and CCHIT argued at the time that usability was too subjective to test. Later, CCHIT came around and added a protocol for testing usability.