"Click Reduction" May Be Just What The Doctor (and Nurse) Ordered
Many healthcare organizations deployed an electronic medical record (EMR or Electronic Health Record, EHR) more than five years ago. At that time, the goal was pretty much one of electronic documentation - making sure there were places for patient history, vital signs, diagnoses, prescriptions, results, etc. At that time, very little thought was given to things like smart design - to usability.
Most EMRs are built on older frameworks (not natively web-enabled platforms). While certified EMRs must conform to ONC standards (MU, UCD frameworks), how they're designed as a software application and how they are configured and implemented by an organization are not the same thing. Think of it like this. Microsoft makes Microsoft Word. In that application, you can do create an almost infinite number of variations from templates to fonts to format and beyond. Microsoft may put the buttons where you need them most, but is the Word document you create readible? Is it useful for the intended purpose? That's far beyond Microsoft's control and it's not what they're selling.
Today's consumer - physician, nurse, care provider, patient - is also a consumer of broader technology. Almost everyone (in the U.S.) has shopped online, used mobile apps to find restaurants, rate hotels, share photos and more. Each of these experiences is fine-tuned to capture the consumer quickly, engage them in the desired activity and make it as quick, as intuitive and as painless (or fun, depending on the objective) as possible.
Do any of those attributes apply to an EMR you know? Probably not. I've seen a few new healthcare related apps that specifically were designed to reduce the number of clicks. One in particular went through numerous exruciating revisions to reduce clicks futher and further until almost everything was one click - bt that still seems to be a rare exception.
The oportunity facing us today is to incorporate this sense of "less is more", to reduce clicks, to reduce "application drag" so that the EMR is more streamlined, fewer clicks and easier to navigate to find needed information. This needs to be incorporated into every project we undertake, every upgrade and service update we implement, every workflow we analyze. Unfortunately, the folks who need to do this work will be constrained by two key factors: the complexity of patient data and the layout, organization and framework of their EMR system.
Complex Patient Data
Think back to 30 years ago. What data did we have about patients? We still had some of the same basic data - history, diagnoses, lab and imaging results - but the scope of medical care was not as broad or as complex as it is today. In just about every field of care, there are new and significantly expanded types of patient data that inform patient care. In addition, due to our ability to store and analyze larger volumes of data (as compared to 30 years ago), we are using data in new ways for population health and patient engagement.
When you analyze the care provided to a patient from admit to discharge and you look at all the steps taken by all the various providers throughout a three or four day hospital stay, the amount of data can be massive. EMRs are (mostly) great at capturing that data, but not necessarily great at helping the care providers make sense of that voluminous and complex data quickly, easily and intuitively. When we build systems that demand tenacity to locate vital information, we put the patient at risk and we reduce the efficiency of those providing care. This contributes to errors, omissions and higher costs. The EMR was supposed to save us from those things, but interestingly has contributed in new and largely unanticipated ways.
Framework of EMR Systems
While there are some newer EMR systems built on modern application or web technologies, many were developed more than a decade ago and they stand on top of older frameworks. While there's absolutely nothing wrong with this approach to data management, this approach has, at times, created a less user-friendly interface than might otherwise be desired.
This problem is so pervasive and so impactful to patient care that the Joint Commission updated their Sentinal Event Alert (SEA #42) to discuss issues and challenges healthcare organizations face with respect to managing their EMR. This SEA #54 (released March 2015, found [here]) provides useful guidance for anyone interested in improving their EMR to provide a more streamlined and usable experience to healthcare providers.
A recent article on EMR usability underscores this problem. American Nurses Association President Pamela Cipriano stated "While everyone was so busy trying to get their systems in place for Meaningful Use, we kind of forgot that the systems are intended to improve quality," she said. "They're also intended to make the workflow better instead of just automating lots of old pieces of paper and lots of old checklists and lots of silos of communication. We've created multimillion-dollar systems that may have seen their best days 20 years ago." [source: FierceEMR article 02.04.16].
EMR vendors have this in their sights and more and more healthcare IT departments are also looking at this problem. Some of the steps being taken today are vendors undertaking usability studies to see how hospitals and healthcare providers have configured the EMR. They're working with IT departments to look at workflows, configuration, build and features to determine how they can contribute to improving the end user experience.
Healthcare IT and Usability Expertise
How many healthcare IT professionals have studied or worked in the area of usabilty? In my experience, very few. It's not what we hire for nor what we train. Going forward, it will become a competitive advantage for healthcare IT departments to have expertise in usability. We'll need to understand how the EMR is designed and how to best configure it for use in our environment that groups data in a logical manner, makes finding patient data easier with fewer clicks.
We also need to look at usability within the construct of the EMR. Analyzing physicial and logical workflows, reducing steps, reducing complexity and reducing clicks are all part of the solution. How each healthcare organization addresses this will differ, but it seems everyone will be looking at simplifying and standardizing as a way to improve the EMR and the end user experience with the ultimate goal of improving patient care and reducing cost.
Maybe some of the big online websites have ruined things for all of us...or maybe they have just pushed us to take a fresh look at the applications we run in our organizations with a new perspective. What would our EMRs look like if we simultaneously focused on capturing needed data in a useful and organized manner AND significantly reducing the number of clicks needed to input or access critical patient data? What if our EMR behaved a bit more like a streamlined online retail site? How would care improve? How would care providers respond to an easier-to-use EMR?
Chime in if your organization has found a unique or successful approach to solving this problem. Those who solve this today will be the champions of tomorrow.