No one will ever care more about software workflows and usability than the people who use them. No one.
What this means in practical terms is, if you are a clinician unsatisfied with your EMR workflow and usability, you need to get involved. Looking to "others" to do this for you, even trying to hang this on the vendors (an apparently satisfying but superficial answer), will not work.
I can hear the objections now, but none of those matter. Success at work is all about overcoming obstacles. Want a difference? Make a difference. The pathways for doing this are many and Healthcare Informatics is just one possibility.
Cosmos - 5 years ago
Great question and great responses. Thank you Mr. HIStalk! Two quick points to add:
I work for a vendor. Our nursing development team spends half their time meeting regulatory requirements and the other half of their time dealing with patient safety events and customer escalations. At the end of the day, usability improvements always take a back seat to the demands of the moment. In my experience, Major milestones in usability only come with new product launches, and those take years.
Also: Suppose we woke up tomorrow to a headline announcing that the FCC now mandated Bluetooth, NFC, GPS, dual cameras, and 4G LTE on all new cell phones. Even though Apple and Android comply by default, a bunch of other products would have to come off the market, stifling competition, and we would decry government overreach, right? Why do we then insist on government's heavy hand in health care regulation? Do the "patient safety" benefits outweigh the anti-competitive risks? This is why I voted "Government" in your poll.
Industry Stalwart - 5 years ago
So it is the insurance companies, in my opinion, that resulted in the EMR morass we see today. I happen to include CMS in that, since they too are an 'insurance company' and I read 'government' as being a legislative body in lieu of agency. Maybe that would change my mind, but not for now. I get that HITECH spawned a lot of this, but people could have always opted out.
Because we have so many requirements to be compensated for work, we need systems to support them. It is just that clear. If this wasn't the case, you'd see more applications for documentation and review that don't have a specific tie-in to financials.
If the insurance companies devised a better way to compensate for care in which the quality of documentation was included, rather than the 'checking of boxes', things would dramatically change from a physician perspective, which is what this question specifically asked.
This doesn't absolve others from fault here. There has been too little attention paid to the long-term ramifications and effects of crap-EMR systems from a provider usability standpoint. I think the providers, their health system executives, the government, and attorneys have not done enough to re-balance the need for quality compensation tools as well as documentation tools. So the blame is shared, but jeez, the insurance companies that need providers to care for their insured lives have had a solid hand in the requirement for systems to be incredibly difficult for physician use.
So there are my 2 cents. I blame insurance companies for in many cases, killing both patients and providers in their quest for profits.
I chose government among the many with shared responsibility as a proxy for the Axis powers of WWII. They were the ones who forced our hand in creating an employer-based health insurance system, which brought us a third-party payer system, which drives skewed reimbursement models. Our further unnatural evolution of EHRs was driven my Meaningful Use, which pushed us over the adoption hump, but created land-grab incentives for installing systems that weren’t user and patient-care driven. Ironically, science and innovation are also to blame as we continue to advance care options faster than we mature our full systems-level understanding of it. If we stopped inventing any new treatment options and stopped advancing our understanding of disease, instead focusing on just implementing what we currently know more effectively, we would probably do more to improve care and outcomes than any scientific breakthrough.
xxxxx bbbbb - 5 years ago
1. Administrators and IT departments not taking into consideration the time and effort that it takes Clinicians to participate and offer suggestions. Scheduling and extra support in the departments to allow the Clinicians to participate would be hugely beneficial.
2. Appointing Champions in every department to participate including physicians who can lead.
3. Project Managers who are not overwhelmed with too many projects to effectively manage.
Frank Poggio - 5 years ago
It has to be clinicians since all of the vendors have MDs-clinicians at all levels on staff. And BTW the old slam that EHRs were built as an by-product of financial/billing systems is a dead argument. Both of the leading vendors (Epic and Cerner) did NOT have financial/billing systems until long AFTER they had installed clinical packages. Since most documentation requirements are promulgated by the govt and insurance companies we should blame them as well.
EHR Girl - 5 years ago
I agree that there is a lot of 'blame' to go around. I also will say that after being in this industry since 2000, some of the things I saw were vendors trying to create a computerized medical record that somehow wrapped around their billing systems, most physicians early on took a very hands off approach and didn't show much interest in give much time to being involved in the EMR's development, perhaps the government should have done a little more research on whether the current status of EMRs was ready for prime time before they trotted out the 'carrot' of HITECH incentives. I could probably go on but those are some that are top of mind. Although I do believe that the axiom 'you can't improve what you cannot measure' holds true, in hindsight, there are lots of places this could have been rolled out better. If I could have changed ONE thing it would have been to find a way for clinicians to understand that vendors can't get into their mind and understand how they want their workflows to be and what functionality they need to do their job if they don't make the time to talk with vendors and let them know. As the saying goes, 'if you know one physician's workflow, you know one physician's workflow. Let's hope these situations can still be improved!
Evan Steele - 5 years ago
Ease of use is a feature which, like any other feature, requires time and money to produce. It's a guns or butter decision and too many vendors have chosen to cram in as many functional features at the expense of usability. Of course, the government having published waves of highly prescriptive requirements made it even harder for vendors to invest in ease of use.
Dean Sittig - 5 years ago
All of these stakeholders have a role to play in that they either set unrealistic requirements or placed untenable constraints on the content and processes of documentation of care. On the other hand only the vendors actually created the software and they didn’t do a very good job in addressing these requirements or constraints in their software. The challenge now is to develop usable systems before, or change the requirements in time, to keep clinicians engaged in the process of providing care and helping design new systems. We begin addressing these issues in this paper. https://www.ncbi.nlm.nih.gov/pubmed/28716376/
No one will ever care more about software workflows and usability than the people who use them. No one.
What this means in practical terms is, if you are a clinician unsatisfied with your EMR workflow and usability, you need to get involved. Looking to "others" to do this for you, even trying to hang this on the vendors (an apparently satisfying but superficial answer), will not work.
I can hear the objections now, but none of those matter. Success at work is all about overcoming obstacles. Want a difference? Make a difference. The pathways for doing this are many and Healthcare Informatics is just one possibility.
Great question and great responses. Thank you Mr. HIStalk! Two quick points to add:
I work for a vendor. Our nursing development team spends half their time meeting regulatory requirements and the other half of their time dealing with patient safety events and customer escalations. At the end of the day, usability improvements always take a back seat to the demands of the moment. In my experience, Major milestones in usability only come with new product launches, and those take years.
Also: Suppose we woke up tomorrow to a headline announcing that the FCC now mandated Bluetooth, NFC, GPS, dual cameras, and 4G LTE on all new cell phones. Even though Apple and Android comply by default, a bunch of other products would have to come off the market, stifling competition, and we would decry government overreach, right? Why do we then insist on government's heavy hand in health care regulation? Do the "patient safety" benefits outweigh the anti-competitive risks? This is why I voted "Government" in your poll.
So it is the insurance companies, in my opinion, that resulted in the EMR morass we see today. I happen to include CMS in that, since they too are an 'insurance company' and I read 'government' as being a legislative body in lieu of agency. Maybe that would change my mind, but not for now. I get that HITECH spawned a lot of this, but people could have always opted out.
Because we have so many requirements to be compensated for work, we need systems to support them. It is just that clear. If this wasn't the case, you'd see more applications for documentation and review that don't have a specific tie-in to financials.
If the insurance companies devised a better way to compensate for care in which the quality of documentation was included, rather than the 'checking of boxes', things would dramatically change from a physician perspective, which is what this question specifically asked.
This doesn't absolve others from fault here. There has been too little attention paid to the long-term ramifications and effects of crap-EMR systems from a provider usability standpoint. I think the providers, their health system executives, the government, and attorneys have not done enough to re-balance the need for quality compensation tools as well as documentation tools. So the blame is shared, but jeez, the insurance companies that need providers to care for their insured lives have had a solid hand in the requirement for systems to be incredibly difficult for physician use.
So there are my 2 cents. I blame insurance companies for in many cases, killing both patients and providers in their quest for profits.
I chose government among the many with shared responsibility as a proxy for the Axis powers of WWII. They were the ones who forced our hand in creating an employer-based health insurance system, which brought us a third-party payer system, which drives skewed reimbursement models. Our further unnatural evolution of EHRs was driven my Meaningful Use, which pushed us over the adoption hump, but created land-grab incentives for installing systems that weren’t user and patient-care driven. Ironically, science and innovation are also to blame as we continue to advance care options faster than we mature our full systems-level understanding of it. If we stopped inventing any new treatment options and stopped advancing our understanding of disease, instead focusing on just implementing what we currently know more effectively, we would probably do more to improve care and outcomes than any scientific breakthrough.
1. Administrators and IT departments not taking into consideration the time and effort that it takes Clinicians to participate and offer suggestions. Scheduling and extra support in the departments to allow the Clinicians to participate would be hugely beneficial.
2. Appointing Champions in every department to participate including physicians who can lead.
3. Project Managers who are not overwhelmed with too many projects to effectively manage.
It has to be clinicians since all of the vendors have MDs-clinicians at all levels on staff. And BTW the old slam that EHRs were built as an by-product of financial/billing systems is a dead argument. Both of the leading vendors (Epic and Cerner) did NOT have financial/billing systems until long AFTER they had installed clinical packages. Since most documentation requirements are promulgated by the govt and insurance companies we should blame them as well.
I agree that there is a lot of 'blame' to go around. I also will say that after being in this industry since 2000, some of the things I saw were vendors trying to create a computerized medical record that somehow wrapped around their billing systems, most physicians early on took a very hands off approach and didn't show much interest in give much time to being involved in the EMR's development, perhaps the government should have done a little more research on whether the current status of EMRs was ready for prime time before they trotted out the 'carrot' of HITECH incentives. I could probably go on but those are some that are top of mind. Although I do believe that the axiom 'you can't improve what you cannot measure' holds true, in hindsight, there are lots of places this could have been rolled out better. If I could have changed ONE thing it would have been to find a way for clinicians to understand that vendors can't get into their mind and understand how they want their workflows to be and what functionality they need to do their job if they don't make the time to talk with vendors and let them know. As the saying goes, 'if you know one physician's workflow, you know one physician's workflow. Let's hope these situations can still be improved!
Ease of use is a feature which, like any other feature, requires time and money to produce. It's a guns or butter decision and too many vendors have chosen to cram in as many functional features at the expense of usability. Of course, the government having published waves of highly prescriptive requirements made it even harder for vendors to invest in ease of use.
All of these stakeholders have a role to play in that they either set unrealistic requirements or placed untenable constraints on the content and processes of documentation of care. On the other hand only the vendors actually created the software and they didn’t do a very good job in addressing these requirements or constraints in their software. The challenge now is to develop usable systems before, or change the requirements in time, to keep clinicians engaged in the process of providing care and helping design new systems. We begin addressing these issues in this paper. https://www.ncbi.nlm.nih.gov/pubmed/28716376/