New-York

NY Times: Seeing Promise and Peril in Digital Records

New York Times reporter Steve Lohr began his article on 7/16 with the following:

“TECHNICAL standards may seem arcane, but they are often powerful tools of economic development and social welfare. They can be essential building blocks for innovation and new industries.”

The standards being referenced are those related to the usability of EHRs and if/how government regulations should limit or direct design choices. The debate centers on the issue of whether use in practice can be accelerated by specifying technology requirements based on research known as human-computer interaction or human factors.

The New York Times article references a report from the National Academies Press written by the Committee on Engaging the Computer Science Research Community in Health Care Informatics chaired by Dr. William W. Stead.

This pre-publication copy begins by outlining three general factors that affect health care delivery:

The tasks and workflow of health care. Health care decisions often require reasoning under high degrees of uncertainty about the patient’s medical state and the effectiveness of past and future treatments for the particular patient. In addition, medical workflows are often complex and non-transparent and are characterized by many interruptions, inadequately defined roles and responsibilities, poorly kept and managed schedules, and little documentation of steps, expectations, and outcomes. Complex care is increasingly provided to patients in a time- and resource-pressured environment because of the need to contain costs.

The institution and economics of health care. The large number of health care payers and coverage plans, each with their own rules for coverage, complicates administration. In addition, incentives for payment are often distorted or perverse, leading (for example) to more generous compensation for medical procedures than for communication with patients or for diagnosis or preventive care. Patients and providers must also navigate a confusing landscape of tertiary care centers, community hospitals, clinics, primary and specialist doctors and other providers, payers, health plans, and information sources.

Current implementations of health care IT. Many health care institutions do spend considerable money on IT, but the IT is often implemented in systems in a monolithic fashion that makes even small changes hard to introduce. Furthermore, IT applications appear designed largely to automate tasks or business processes. They are often designed in ways that simply mimic existing paper-based forms and provide little support for the cognitive tasks of clinicians or the workflow of the people who must actually use the system. Moreover, these applications do not take advantage of human-computer interaction principles, leading to poor designs that can increase the chance of error, add to rather than reduce work, and compound the frustrations of executing required tasks. As a result, these applications sometimes increase workload, and they can introduce new forms of error that are difficult to detect.

I found this statement from the report particularly descriptive of what we hear from practicing physicians regarding the use of their EHR systems:

“The health care IT systems of today tend to squeeze all cognitive support for the clinician through the lens of health care transactions and the related raw data, without an underlying representation of a conceptual model for the patient showing how data fit together and which are important or unimportant. As a result, an understanding of the patient can be lost amidst all the data, all the tests, and all the monitoring equipment.”

[NOTE: For an interesting historical perspective on the evolution of the medical record, see this Annals of Internal Medicine article by Dr. Eugenia Siegler and the commentary I wrote to accompany it.]

The National Institute of Standards and Technology (NIST), through its Health IT portfolio and collaboration with the Office of the National Coordinator (ONC) and the Agency for Healthcare Research & Quality (AHRQ), is taking these issues on (see Usability Framework).

The central issue seems to be whether standards should be put in place regarding usability based on human factors research — and whether doing so would limit innovation. The New York Times article quotes one EHR industry representative expressing concern that such requirements might make it more difficult to improve usability. On the other hand, health IT experts express a different sentiment… from the New York Times article:

“Usability is going to be the single greatest impediment to physician acceptance,” says Dr. Edward H. Shortliffe, a professor at the University of Texas Health Science Center in Houston and the president of the American Medical Informatics Association.

Question: If you could pick one feature or function of your EHR to improve that would make it easier to use and the clinical information presented clearer, what would it be?

This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP). ACP does not endorse a specific EHR brand or product and ACP makes no representations, warranties, or assurances as to the accuracy or completeness of the information provided herein.

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