Providers and vendors team up for user-friendly EHRs
Before an Allscripts electronic health record appears on screen, it first appears on a storyboard—sometimes even a paper one. That’s where Allscripts developers can test new ideas on providers, figuring out what should go where.
“The design on paper is still at the basic level where we can change on a dime,” said Ross Teague, director of user experience for Allscripts Healthcare Solutions. Users usually feel more comfortable offering feedback on a design when it looks unfinished.
Such interaction is crucial, given that clinicians spend about half the workday working with EHRs. And many of those hours are during patient encounters. A study in the
Annals of Internal Medicine found that ambulatory physicians spent more than a third of their time with patients on EHR and desk work tasks. That makes many providers unhappy, and not just because it affects their face-to-face time with patients.
“The challenge of established EHRs is that so much functionality gets piled onto these complex systems,” said Dr. Titus Schleyer, a research scientist with the Regenstrief Institute.
But as providers complain, vendors respond. Allscripts, Athenahealth, Cerner Corp. and Epic Systems Corp. are among those constantly tweaking their software after getting feedback from the source of those complaints. They’re consulting with and observing users inside and outside of their natural work environments to build EHRs for efficient—and pleasant—workflows, layouts and functionality.
Most, if not all, major EHR vendors rely on a combination of formal user testing, informal feedback, and what might be called ethnographic research. The result isn’t just happier clinicians but safer healthcare delivery.
“Many of the same issues that can lead to clinician frustration with EHRs can also lead to safety problems,” said Ben Moscovitch, manager of health information technology for
the Pew Charitable Trusts. For instance, if a clinician accidentally orders a medication for the wrong patient, correcting the error can be cumbersome, requiring multiple steps, he said. The EHR can be tweaked to address that.
A partnership
With healthcare perpetually inching toward value-based care, EHRs are more important than ever in helping patient care. Vendors are working with providers to improve their offerings, going beyond meeting the bare minimum federal requirements for their software.
Athenahealth, Allscripts and others have formal programs to gain insight from their provider users both while software is in development and after. “That relationship has really improved the way the system works for us and, I would presume, because of the way Athena works, for all of its customers,” said Steven Kelley, CEO of Ellenville (N.Y.) Regional Hospital, which, as an Athenahealth development partner, tries out prototypes with new features.
That kind of relationship also helps vendors, which learn from their users early on what kinds of features they're interested in and how those features should work.
“In a good user-centered design process, you're involving your users early and often,” Allscripts' Teague said. His company does formative testing with its users during which they engage in the aforementioned and try new versions of the software. “This is the No. 1 method by which we collect patient-safety issues before they ever become patient-safety issues,” he said.
Allscripts also gets new product ideas by observing clinicians in care settings. Sometimes, for instance, to get an objective sense of how well its software works, Allscripts will measure how many users can complete a certain task without any training.
Observational research is particularly helpful given how providers talk about what they want from their EHRs. “Sometimes, what people say only reflects part of what their goal is,” said Janet Campbell, Epic's vice president of patient engagement. “If you give a doctor a list of 10 activities in the record and you say, ‘How many of these would you like to see on the screen?' they'll say, ‘All,' ” she said. “It's not until you watch how they interact and move back and forth that you realize that they only need three of those things.”
When Athenahealth is testing a feature in the alpha or beta stage, the company uses behavioral analytics to glean how users are interacting with it. “One of the benefits of being cloud-based is that all the data across our network is very accessible, and we can see the actions people are taking,” said Scott Mackie, Athenahealth's executive director of strategy design and user experience.
For instance, when the company was developing a timeline feature, users complained about how many clicks it took to see everything that had happened to a patient over time. Athenahealth developers watched how the timeline affected workflow so developers could lay it out to highlight the most useful and appropriate events and data. Giving clinicians the information they need when they need it could help them better care for patients, since it would reduce their workload and help identify important elements quickly. “Physicians want the right information at the right time at the right point of care, and that helps them provide better care,” said Rich Berner, Allscripts' senior vice president of health systems and population health solutions management.
Presenting information, not data
Part of the reason vendors must revise and tweak EHRs is because of their complexity, Schleyer said. It's hard to design a program that's usable “right out of the box.”
To deliver a more consistent patient and user experience across its facilities, SSM Health consolidated its three versions of Epic into one. “We called the project that we worked on ‘simple elegance,' ” said Philip Loftus, SSM's chief information officer. “If it took you five screens to do something, we tried to bring that down to two or three screens.”
The improvements came from Epic's collaboration with SSM and from SSM's own developers, who get regular feedback from physicians and from consumers surveyed after
the health system updates software.
One request was to display all information relevant to patients’ care on one screen.
Physicians want all of that information at the top level, Mackie said. “They want less digging," he said. A solution could be building artificial intelligence into the EHR so it learns the most important information, he said. Another solution might be voice, especially as it becomes more common in consumer life.
Increased population health efforts also have vendors considering how new kinds of data should be presented.
“People aren’t asking for data—they’re asking for information,” Teague said. “That means fitting it into their workflow and making sure it’s presented in a way where they’re not spending a lot of cognitive effort determining what it means.”
The balancing act
In general, despite these efforts to address problems, providers still have gripes with their EHRs. “Hospital-based physicians consistently conveyed that EHRs have a negative impact on their interaction with patients,” wrote the authors of a study published in the Journal of Innovation in Health Informatics. And in an AMA study from 2016, “meaningful use, EHRs and desk work were identified as dissatisfiers twice as frequently as any other item.”
But vendors have to be careful to respond to providers’ needs while keeping larger goals and demands in place.
“There’s this constant balance between doing the things we’re told we should do by the government and doing the things we’re begged to do by our client base as well, and they frequently do not line up,” Athenahealth’s Mackie said.
While healthcare can and does learn from digital consumer technologies and trends, those can also be misleading. “There are sometimes unfair comparisons to a lot of very high-quality consumer apps out there,” said Paul Weaver, Cerner’s vice president of user experience. Those developers are not thinking about patient safety, he said. “We can’t just concentrate on making things look nice. The overriding element for us in design is to make sure that no harm occurs. I’d rather we measure twice.”
Consumer-app developers also don’t have to take into account the demands of federal EHR programs. Though EHR certification requirements have again been delayed, and meaningful use has been turned into the advancing care information category of the Merit-based Incentive Payment System for physicians, federal EHR mandates still exist.
There’s also what vendors themselves want to do on their own. Vendors must maintain some independence from their users, Regenstrief’s Schleyer said. “Getting feedback is a very valuable activity for vendors, but it doesn’t release vendors from the need to innovate on their own,” he said. “If you just do what your customers tell you to do, you’re probably not going to be around much longer.”