27 comments

Why EHR usability has fallen short

  • Ross Teague, Ph.D.
  • 03/07/2016

A recent article said that electronic health record (EHR) usability is poor because clinicians are not the ones who are designing the products:

“Physicians and other clinician users of electronic health record systems commonly rate the products low on a usability scale, in large part because non-clinicians do the bulk of the work designing them.”

But does usability really suffer because non-clinicians are designing Health IT solutions? When we look at other industries, we don’t see end users primarily responsible for the design of successful products. For example, accountants don’t design banking technology, and writers aren’t developing word-processing software.

Why do products in other industries seem to be more reflective of users’ needs? For EHR usability to improve, do clinicians have to create and design the products, or is there another more impactful way for them to be involved?

I believe usability lags in Health IT because EHR vendors have not applied rigorous user-centered design (UCD) principles. It’s not that clinicians haven’t been involved, they just haven’t been involved in a meaningful way.

5 design shortcuts that can stunt EHR usability

End users must be involved early and often throughout the design process. Some EHR vendors take short cuts, which leads to poor design that negatively affects usability. These vendors call it user-centered design, but they make these common mistakes:

1) Counting demos as feedback sessions

Let’s say an EHR vendor is presenting a new product concept in front of an audience to collect design input and asks at the end of the session, “Any feedback?” This request for input doesn’t go deep enough to provide meaningful input to the solution.

Fix: Preview the solution in one-on-one sessions with actual users performing relevant tasks.

2) Asking too late

When an EHR vendor only collects user input for a new feature or solution just prior to launch, it’s too late for the clinician to give feedback that can affect product design. The product is about to release, and it would be too costly to change it.

Fix: Involve clinicians earlier in the process with formative testing using sketches, wireframes and prototypes.

3) Giving unrelated tasks

Using testing tasks that do not directly relate to patient safety and the specific end-to-end goals of the user do not adequately evaluate the product. Test results aren’t as valuable.

Fix: Rigorously assess tasks before testing them with users. Involve clinicians in designing the tasks to make sure they are clinically relevant.

4) Listening to (only) the squeaky wheel

EHRs should not be designed by the loudest user.  Don’t overgeneralize one person’s experience or feedback when designing solutions.

Fix: Consider each user’s feedback as a single data point in context with other testing results. Use data to explain to your customers why product direction highlights efficiency, reduction of cognitive load and patient safety, particularly when you make a design decision that is not what they suggested.

5) Testing with the right users

All of these other items assume that the feedback is coming from people who are the actual end users of the solution. Too often, designers only collect feedback from the purchaser, who may not have the same background and goals as your intended users.

Fix: Collect usability data from the people that will be using the product for its intended purpose. It’s okay to collect feedback from others (e.g., purchasing, trainers, IT), too, but let user input guide and have the most influence.

Rigorous UCD processes improve EHR usability. Aligning with best practices is the right thing to do for many reasons, the most important for EHRs is patient safety. It also serves as the most effective and efficient way for clinicians to have an impact on the design of a product.

As Health IT catches up with other industries on the application of UCD, clinicians will be appropriately involved and users of Health IT will feel like the products were designed by someone like them.

To learn more about how Allscripts applies UCD principles, download this free white paper.

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About the author

Ross Teague, Ph.D., director of user experience research, leads the cross-functional team that provides user-experience (UX) and user-centered design (UCD) support for Allscripts. His team provides the research, design (conceptual and detailed) and evaluation necessary for the UX needs. Ross also manages the Allscripts effort to meet Meaningful Use UCD requirements and update of our development process to include UCD activities and measures. Prior to joining Allscripts, Ross was partner and director of research at Insight Product development, a design and strategy firm specializing in the planning and development of medical devices. Prior to Insight, Ross worked as a human factors psychologist in a business and design services group at Intel, helping to develop internet based products for companies outside of Intel. Ross holds a Ph.D. in Applied Cognitive Psychology and Human Factors.

27 COMMENTS on Why EHR usability has fallen short

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rat hybridoma says:

03/08/2016 at 1:41 am

Accountants don’t design banking technology, and writers aren’t developing word-processing software. That’s quite a good explanation for whether usability really suffers because non-clinicians are designing Health IT solutions, as we don’t see end users primarily responsible for the design of successful products.

    Ross Teague says:

    03/18/2016 at 8:51 am

    Thanks. The more we can bring designers and users together, each with their own areas of expertise, the better the products will be.

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Ed says:

03/10/2016 at 4:42 pm

Do so-called “Patient Portals” fall within the scope of EHR? Thus far, my experience with 3 of them is less than user-friendly or intuitive. Starting with the fact that all 3 are different from each other, it quickly degenerates from there – ending up miles from any UCD. Of course in PP’s, the end user is the PATIENT, not the clinician. Interesting to note that the word PATIENT appears not at all above. I’m hoping that it’s all because the whole thing is still so young.
I’d appreciate your comments. Thanks, Ed

Ross Teague says:

03/14/2016 at 3:32 pm

Great observation, Ed. Like with some EHRs, vendors rushed to develop portal solutions to meet Meaningful Use deadlines, without optimizing usability in all of their functions. Patient portals require a fresh approach that takes into consideration the content and what healthcare consumers expect related to health information and an access to their healthcare providers they have not had before and can’t rely solely on what works on other consumer facing sites. At Allscripts we are working diligently on improving the healthcare consumer experience for common portal functionality as well as advanced functions such as telemedicine. We conduct research and usability testing with consumers (aka, patients) to understand their reactions to the products and how to improve them. We are also enhancing options healthcare consumers have to access their information on a variety of platforms that provide a unified experience. User-centered design methods help to make this an experience that healthcare consumers and providers can benefit from.

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Naser says:

03/16/2016 at 4:18 pm

Great post here thank you for this article. Here you are my 2 cents:
Projects in healthcare, like anywhere, are constrained by the triad of scope, time, and budget. We all know other factors come into play like resources (include the clinicians mentioned in your article), risks ( I will talk little about that), and in my humble opinion your article refer to the “Quality” constraint; because in healthcare if you did not consider the quality of your product you have to do it all over again.
My question here is: what do you do to the new technologies promoted out there, including Allscripts products, which fail to deliver its promise? I am a clinician and actively involved in developing a product, it looks elegant but too slow to be used in production and too frail for patient care.

    Ross Teague says:

    03/18/2016 at 8:52 am

    Thanks, Naser. Many of these promises that get missed are a result of not designing, testing, and programming with measurable goals in mind from the beginning. The ‘promise’ of the product needs to be operationalized as measurable usability goals that everyone agrees to from the beginning and when tradeoffs are required (due to the triad you mentioned) they are kept in mind. User testing that happens throughout design and development needs to measure against these metrics to determine if you’re addressing the issues or not. Waiting until the product is coded or worse, launched, is not when you want to find out that you have not met the promises of the product.

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Monica Grider says:

03/16/2016 at 4:24 pm

I find it interesting that Allscripts would blog about the frustrations that clinicians have with EHR when the Allscripts Care Management site is very un-user friendly! There’s no option to select multiple medical records at once in order to print them. You have to select each document one at a time and print them one at a time hoping you haven’t missed anything. The competitor site is much more user friendly.

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M CARSON HOLBROOK says:

03/16/2016 at 5:10 pm

My daughter, a millenial, was a recent patient that had an experience with the FMH patient portal. I asked her how “user” friendly and intuitive it was. She gave it A 4 out of 10, saying it was not that intuative. Having the Medfusion portal taken away and replaced by FMH did impact our patient participation with portal use adversely. For some specialities who participate in MU whose patients are much older portals can be clunky for elders who are not tech savvy. And perhaps to encourage medicaid patients to use the portal perhaps making the portal more “gamelike” and utilize easter eggs to be redeemed for instance, infant formula (of course I am referring to pediatrics).

    Ross Teague says:

    03/18/2016 at 8:51 am

    Thanks for the feedback. We’re working on moving your daughter’s “4” rating to the other end of the range. Our updated FollowMyHealth Mobile app is 5-star rated on the App Store (with 2765 reviews) which is in the right direction, but there is still work to be done. We are visiting with groups of healthcare consumers and hosting participatory design sessions to understand their needs and uses for their portal and we’re conducting 1-on-1 usability testing sessions with users on new functionality in FollowMyHealth that should make the overall experience better for all of the portal users. Your suggestions of ‘Easter eggs’ and other gamification activities are all being explored to engage the user. Their involvement is so critical to improving their health.

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Tom Hubbell says:

03/16/2016 at 7:55 pm

The traps of EHR that interfere with usability:
1. Drs are fairly compulsive, if there’s a drop down, or a box, or another menu they can hardly resist clicking forever to create the perfect note (instead of the good note), except,
2. Drs. are mostly focused on the patient; ‘get me to the orders page and make it quick, like my usual, and done, except,
3. Drs. need to get paid for what they actually do which means checking enough boxes to satisfy the clerk in Kalamzoo approving claims using a compliance grid, except,
4. Patients expect the record to not interfere with the doctor ordering and doing what is best for them, except,
5. The hospitals (locale of many expensive testing elements,) can’t seem to find satisfaction in the fact that one of the doctors on their staff ordered the damn test -so just do it, except,
6. The office staff has to play referee and EMR-documentation jockey between patient, doctor, hospital, pharmacy, and insurer (and the fact that there is a lot more to do in the office besides this stuff) to just get the doctor’s order carried out, and
7. By the way, the whole EHR utilization is very expensive and that cost is a serious thorn in the side of the doctors – to the point that it is difficult to remember the fast, accurate, information retrieval that is so fantastic it is worth the expense, Allscripts being among the more expensive.
That is a lot of competing interests and goals. Meeting one goal should not interfere with meeting another goal, but so far it is chaos.
Please keep working on it!

    Ross Teague says:

    03/18/2016 at 8:50 am

    Thanks for taking the time to create this list, Tom. I’m going to share it with my team. Your final point about meeting one goal not interfering with another is important. We won’t be successful with Heath IT usability if we all (vendors, organizations, clinicians, regulatory, etc.) don’t think about it from a systems perspective. Healthcare is a good example of a complex socio-technical system. We can and should meet multiple goals, but we have to keep in mind that what happens in one area, impacts other areas. I think we’ve seen this where EHRs have optimized for billing and regulatory at the expense of the clinician experience.

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Dustin D says:

03/17/2016 at 7:29 am

All EHR vendors scrambling to meet and adapt to the changing Meaningful Use requirements. That’s the main reason. Non-iterative design process, that’s reason #2.

    Ross Teague says:

    03/18/2016 at 8:49 am

    Dustin, I would agree that the focus on MU requirements have had an impact. Our goal is to build our UCD process into our development process in such a way that when time/resources are tight, usability doesn’t get squeezed.

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David Groen says:

03/17/2016 at 7:31 am

EHR’s have made most physicians very inefficient as providers and actual documentation of the patients problems have become overly complicated at best. The EHR only provides an efficient way to store and retrieve data and reports that are often meaningless and useless assortment of disorganized data. The EHR rarely assists me as a physician to be a better provider of healthcare and assist in appropriate diagnosis of a patients condition or disease process. EHR as now gotten to the point at which we need to hire a scribe to enter information into a useless form to meet government “meaningful use” guidelines. “meaningful use” is only another rung in the ladder of trying to be paid for services rendered.

The EHR will continue to be a useless tool in the physicians office until it can become intuitive as to questions and test to run and expand from questions or findings already input or asked of the patient. If the EHR could take the patients CHief complaint and description of their condition or pain and formulate or propagate a suggested series of pre approved questions or tests to help direct a diagnosis or plan of treatment in an efficient and timely fashion will EHR’s become a useful tool in a physicians office or hospital.

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alan shain says:

03/17/2016 at 10:25 am

I had some early experience with allscripts after some changes they made on an upgrade concerning the ability to sign off on labs en masse rather than individually. In that particular incidence it turned out they had very small number of beta sites for doctors and those doctors just said every one signs off each lab individually so they removed a fairly easy way to sign off on groups of tests. Allscripts has pushed the democratic method for making changes while I believe there is the “genius” functional designer out there who should channel these changes. Not to overdo a cliche in the computer world but Steve Jobs was that type of person, I think the first EMR company to find that talent (usually a team of 2 to 3 persons) will win the EMR war for business.

    Ross Teague says:

    03/18/2016 at 8:48 am

    Alan, we’re starting to hear more organizations say the same thing about vendors being more prescriptive, but it comes with a caveat. That is, for vendors to be able to be more directive and less likely to build anything that the loudest doctor in the room asks for, vendors must follow a proper user-centered design process. That process, while built on collecting user feedback, also brings solid human factors, perception, and cognitive psychology to deliver a solution that is effective, efficient, and satisfying to the users and balances user needs/goals with what will lead to the best design.

Ross Teague says:

03/18/2016 at 9:22 am

Thanks for your feedback, David. Your comments reflect what many users are feeling right now. Combining our UCD process with explorations of how technology can learn, suggest, and guide, Allscripts is working toward continuous improvement in many of these areas.

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kirby says:

03/18/2016 at 6:40 pm

In my current allscripts configuration, I’m unable to make my own templates or “canned charts” for the common problems that have universal features such as:

URI
Ear infection
urinary tract infection
sore throat
toothache
ankle sprain

I’ve used a dozen or more EMRs over the years. All of them allowed the end user the ability to reduce time and clicks to document a common problem. If one invested the time up front to make a dozen or so of these common problem “canned charts with their classic symptoms and findings, they saved tons of time.

I’ve never seen an EMR not capable of this, until I began using Allscripts. So for a common cold the chart needs EVERY symptom and finding completed every time, instead of applying the canned chart that automatically populates sinus congestion, mucous, scratchy throat…etc.

When I realized this limitation, I was referred to the hospital’s IT allscripts person. She said it takes a lot to build a note like this. I find this hard to believe because any EMR that could be considered a helpful and competitive, comparable product would have this customizability.

I began conscientiously ‘counting clicks’ for common charts to get a feel for why a simple head cold chart would take 15min when I go as fast as I can without interruption (rarely possible in an ER). The typical click count is 60-90 clicks if anyone can believe this. I wear a copper bracelet now as i’ve heard it helps the elbow tendonitis…

Am I missing something or is my IT representative misinformed?

Please direct me to the authority in creating personalized custom canned charts. In a busy ER, this allscripts version is unsustainable and we will be forced to abandon it if it fails to facilitate Doctors and nursings’ ability to efficiently give safe care. I’ve heard we will have upgrades. It will need the aforementioned feature at bare minimum to make the cut when volume increases. So far the only reason we can still utilize it is because we’re not often busy. But when we are, we keep stickers and write notes and chart 90 clickers later after shift. If we have even 4 patients/hour even the scribes cannot keep up.

Am I the only one experiencing this?

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Joseph Ng says:

03/22/2016 at 6:46 am

As an end-user for both Sunrise Acute Care and EPIC and as a CMIO, I find that the design decisions that are based around design sessions with us users (orders reconciliation, which at launch was a disaster and is now one of the better orders Rec modules out there) end up with more user friendly and workflow friendly products.
Also, when enhancement requests are submitted, they are submitted by a third party IT specialists/analyst and requests are usually paraphrased. These requests are further diluted when the person fielding these in AllScripts reinterprets them and the true requestor which is a clinician, never hears about this ever again. I’m sure this is a horrible client satisfaction issue.

    Ross Teague says:

    03/22/2016 at 11:00 am

    Joseph, we continue to see good examples of improved products as we engage users like you described. As important as it is to include users DURING the design process, this needs to continue during and after implementation.

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Denise McFarland says:

03/22/2016 at 7:31 am

This is a decades old problem , from placing equipment behind patient beds, out of reach from nurses, poor room design, all the way to the EHR, staff persons have not been truly consulted. It reduces our ability to care for our patients.

    Ross Teague says:

    03/22/2016 at 10:59 am

    Thanks, Denise. It seems like common sense that you would put equipment where it can be reached and design interfaces that fit how users want to work. I do know that equipment and HIT vendors are not purposely trying to create a bad experience and reduce ability to care for patients, so why does this happen? In many instances developers rely on the fact that the most flexible, adaptive part of the equation is the user. Humans are fantastic at adapting, but it comes with a cost. Many times the costs are hidden (increased demands on cognitive resources) in addition to the ones that are easier to identify. The impact of poor usability to patient safety, efficiency, and the business of health care are being made clear now, such that user-centered design is being viewed and applied at a level similar to other development processes.

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Michael Kolinsky says:

03/22/2016 at 3:00 pm

I have now used three of the top 10 EHR. They are all basically a check off sheet to document a history and physical, an unintuitive order module unrelated to patients complaint, age, history, vital signs, physical findings, or previously available medical information (in that same EHR), and a database of ICD-10 diagnoses. The final work product nicely ties together the history, physical, labs/xray/etc results but does so including a morass of inconsequential data that really has no relevance to care of the patient, i.e. rendering the chart near useless and anyone trying to glean useful information from it ignores all but the free text narrative, if they can find it.

Has anyone from the development team listened to physicians dictate their office/hospital/operative notes, history/physical, ED encounters ??? Or have they read any of these same transcriptions ??? There must be some place that still does this though it is getting to be a lost art. I would guess that for the non-medically trained ear it would take listening to several hundred hours or reading through several hundred transcriptions to get a feel for the physicians’ thought process. But if all the developers have is a format which might be culled from a medical student’s introduction to taking a history and performing physical exam, then the final product isn’t surprising. In order to think like a physician, you have to know how they think.

If the sum purpose of the EHR is data collection, the products you already make have mastered that. If you are aiming for a product that will actually aid physicians in clinical decision making, there’s a lot more work to do. One of my best learning experiences as a medical student was when I was taught by one of the senior residents that the history was more that just an account of what had happened to the patient. It was the foundation of the differential diagnosis which would guide the patient’s work up and treatment. The disconnect between the history/physical module and the diagnostic/therapeutic (orders) module of every EHR I have worked with is complete, like they were two unrelated programs when they should be integrated and seamless. The history, physical, and prior diagnostic results (prior visits) should form the differential diagnosis and tee up the diagnostic work up.

In the first two years of medical school the student learns the language of medicine. The third and fourth years the student is introduced to clinical medicine. During post-graduate training the resident learns clinical decision making which he/she will use for the rest of their professional career. EHRs have mastered the first two steps but have yet to integrate this final step. Without that you have little but a glorified check list.

    Ross Teague says:

    03/23/2016 at 11:14 am

    Unfortunately, many EHRs started and were evaluated as a replacement for paper medical charts, not as clinical decision support tools.The focus on data entry has been reinforced by billing and regulatory requirements. Clinical decision support is happening, but it’s tough to build on top of this foundation.

    But that’s shifting. The factors that pushed these products to be this way are now pushing these products to be more about what you get out of the EHR. This includes clinical decision support but also accountable care and population health data. Products are starting to leverage the power of the technology more to address decision making both at the point of care and in risk management.

    To learn how clinicians think, we’ve found that just talking to them isn’t enough. We incorporate contextual research methods that get us into the environments with clinicians, observing them work within their context over time and in different contexts. Using Allscripts clinicians (we have many at Allscripts and four who are members of our UX team) we are able to translate what we learn in this research to actionable design directions.

  • Pingback: EHR antagonism needs a new narrative | Health Standards

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    Bob Coli, MD says:

    04/13/2016 at 1:21 pm

    I just saw the reference to your blog comments about limited EHR usability in Edgar Wilson’s Health Standards posting here: http://healthstandards.com/blog/2016/04/07/ehr-antagonism/ and I read your UCD White Paper.

    One important user interface desperately in need of a complete redesign based on UCD principles and meaningful clinician involvement is the infinitely variable interface still being used by EHR, PHR and HIE platforms to display the cumulative results of billions of diagnostic tests to both physicians and patients as hard to read, incomplete and fragmented data. Although still largely unrecognized, this flawed design insidiously disrupts physician workflow, decreases test results usability and patient safety and increases unnecessary testing costs.

    The logical solution is to use a clinically intuitive, standard reporting format that can display complete, integrated and actionable information and allow physicians and patients to efficiently view and share an unlimited number of results. As described here: http://www.emrandehr.com/2015/12/29/an-improved-interface-for-lab-tests/, a group of Rhode Island physicians has independently developed working prototypes of just such a standardized reporting format. Unfortunately, in the volume-based reimbursement era, with immature IT standards and the special innovation barriers of a highly regulated marketplace, we were unable to complete development of a market-ready hospital lab product. Since then, because the problem remains unsolved and the market need has greatly intensified, we have continued our product development efforts. The practical, long-term value of significantly improving the usability, information density and pragmatic interoperability of diagnostic test results is demonstrated here: http://diagnosticinformationsystem.com/examples.html, and additional current documentation and details are here: https://www.linkedin.com/in/robert-d-coli-m-d-b923207.

    Fortunately, twelve years after the appointment of the first ONCHIT Director, fee-for-service is finally yielding to fee-for-value and the “Quadruple Aim.” (http://www.annfammed.org/content/12/6/573.full) At the same time, open platforms and APIs and physician and consumer-facing Care Management applications are proliferating, along with SMART® on FHIR “App Ecosystems” and the interoperability-advancing initiatives of the Health Services Platform Consortium (HSPC), the Argonaut and Sequoia Projects and the CommonWell Alliance. As a result of these developments, some EHR and health system executives are now calling for “EHR standardization” and suggesting that open, standard platforms “would allow some vendors to compete on clinical applications rather than infrastructure.” http://www.modernhealthcare.com/article/20160408/NEWS/160409893)

    In view of Allscripts’ unique Open architecture and strong emphasis on improving EHR usability, do you think the company might consider exploring a collaborative effort to significantly improve the usability and interoperability of test results data for both physicians and patients?

      Tina Joros says:

      04/14/2016 at 8:57 am

      Dr. Coli – We are more than willing to consider a collaborative effort that helps address the issues you’ve identified in your post. Today, you can register for a free account on our Developer Portal to start building out your solution. If you are encouraged by the technical options you see there, we can set up some time to discuss a partnership with Allscripts through our Allscripts Developer Program to make your solution available to Allscripts clients. To get started visit http://developer.allscripts.com.

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