EMR Quote of the Day comes from a comment on one of my most popular posts:

“An EMR is not a paper chart on the computer screen and as long as users think that way, complain when it doesn’t work that way, and vendors design that way… there will be issues with electronic medical records.”

I’ve been sitting on this post for a while. I figured it was finally time that we talked an interesting development in the CCHIT EHR certification: EMR usability testing. They first presented some of the details of this testing during the CCHIT training meeting. However, they also partnered with User Centric to formulate their EHR user testing and EMR and HIPAA has had a nice connection with User Centric for a few months now.

First the good. I’m glad that CCHIT is venturing into the realm of EHR usability testing. I’ve often talked about CCHIT Certification being rather useless since just because a piece of software does a certain function doesn’t mean that it does it well or that the EMR is usable. In fact, some of the most “feature rich” EMR software is completely unusable by the majority of people. Kind of reminds me of the days of terminals. If you knew the key strokes, it was incredibly efficient. However, learning the keystrokes was so much harder than a nice graphical interface which could do the same things. Not a perfect comparison, but interesting to consider.

So, the biggest problem with CCHIT measuring an EMR’s usability is that the EMR usability rating does NOT affect the certification outcome. Also, it appears that it will be up to the EMR vendor whether they want this result published or not. I wonder if we’ll get to a place where a few EMR vendors show their usability rating and others don’t. Those that don’t we’ll have to assume scored poorly? We’ll see how all that plays out.

I admit I haven’t looked over the entire EMR usability rating process. So, I can’t say if the process is complete or effective in and of itself. Although, I do have some confidence in User Centric as a company even if they’re trying to bite off the very difficult task of measuring EMR usability.

It does look like they’ll give the EMR software a usability rating that is not just a pass fail score. A rating is a much better thing when we’re talking about a somewhat abstract concept of software usability.

I’m also concerned about the quality of the jurors that they’ll use to try and measure usability. I’m sure they’re great people with great intentions. Honestly, that’s one of the most redeeming qualities of CCHIT. They have a large base of volunteers that are very well meaning. However, I’m not sure how much confidence I have in their ability to rate a software’s usability. For that matter, I’m not sure how well I’d be able to do it and I think I’m pretty familiar with the subject.

In a related issue, when you look at the way their putting together the score, it seems pretty complicated at first look. Like I said, I don’t know the details of the methodology. However, that’s kind of the point. Even if CCHIT does post an EMR vendor’s usability score, will the listening public (Translation: doctors) be able to quickly and easily understand what that score means? Maybe it’s a simple thing to figure out. We’ll see, but the devils always in the details and if I’m selecting an EMR I want it to be usable. So, I’ll be very interested in an EMR’s usability score.

Those are just a few things I noticed with the new CCHIT EHR Usability additions. Is there some other parts of it I missed? Anything else we should know about it? Will this be a valuable addition to the CCHIT Certification? Will EMR vendors revolt against it?

I’ve gotten a couple emails from people suggesting that I should write about the current and potential EMR backlog that is happening in the healthcare IT industry. It’s something I’ve discussed tangentially when talking about EMR and the ARRA EMR stimulus money. Basically, some EMR companies have been making the case that doctors and clinics need to make there EMR selection now in order to avoid the EMR backlog that will occur for an EMR vendor once we know the full details of “certified EHR” and “meaningful use.”

Dr. Jeff at EMR and EHR pointed me to a section of the newsletter by XLEMR that provides another perspective on the EMR backlog.

Once preliminary certification begins in October, EHR demand should surge. Although the market is currently slow, many vendors have installation backlogs. Preliminary certification may cause those backlogs to increase. Physicians who are in the “wait and see” mode will need to make a decision quickly. Waiting could result in long delays that may jeopardize the ability to qualify for the first year of reimbursements. One alternative is to purchase a simple system. Simple systems take much less time to install, so backlogs are not a problem. Simple systems are also easier to learn, meaning you do not use as much valuable time for training instead of seeing patients. Finally, simple systems are easy to use, giving you more time to qualify for meaningful use. Be sure to ask any EHR vendor if they have any backlogs, and how long it takes to implement their system. Their answer will tell you if their system is simple.

This type of tongue and cheek style of writing is right up my alley. It makes a really interesting point and you can’t help but laugh when you get to the end.

Some might argue that the EMR is so good that the demand for it is so high and that’s what creates the EMR backlog and not the fact that the EMR isn’t simple to use and requires a lot of training and work to implement. I’d suggest that the EMR backlog is probably a combination of high demand for that EMR and the EMR not being very easy to implement/use. However, the high demand for most of the EMRs with a backlog has little to do with how great the EMR is and has more to do with that EMR company’s ability to market and sell their EMR.

Today’s the final day for providing feedback on meaningful use to ONC. I find it a little bit ironic that as ONC and healthcare IT in general is stirring about the words “meaningful use” I find a survey by Nuance that shows that 90% of doctors are “concerned” about the usability of EHR.

This figure probably isn’t surprising to any of you out there that have worked in the EHR industry for a while. The usability of the EHR has been one of the big barriers to EHR implementation for quite some time.

I hope that no one is naive enough to think that requiring a bunch of features and reports to show “meaningful use” or “certified EHR” that we’re somehow going to make EHR software more usable. In fact, the opposite may be more likely.

I can just see in my minds eye a bunch of EHR programmers slapping in some half baked code in order to satisfy some “meaningful use” or “certified EHR” criteria. Yes, it probably will meet the criteria, but at what cost to the end user? I’ve very rarely known quickly created software to be very usable. Understanding and implementing usable software takes thoughtful planning to execute correctly. Someone who understands how to simplify the process while still implementing the necessary features.

In the rat race for EHR stimulus money, I predict that usability of EHR systems will actually decline rather than improve.

I recently saw a newsletter done by User Centric that had a couple interesting pieces.

First, Dr. Wendy Yee writes, “Most HCPs will bluntly tell you that they did not go through medical training to become data entry clerks. They also are highly sensitive to time requirements because their days can be brutally compressed.” Sounds a lot like my post EHR Software Makes Doctors Secretaries.

Dr. Yee also provides an interesting list of multiple items that are simultaneously going through a doctor’s mind while using an EHR:

• There must be a way to make order entry faster…
• What was the procedure code for that variation of a genetic test?
• Let’s see, should I order Test ABC or Test DEF (or both)?
• I need to check for Jane Doe’s lab results from yesterday.
• Why isn’t that med listed under antivirals?
• What does that obscure lab reading mean?
• Has the patient’s problem list changed in the last day or so?
• Why do I have to enter patient notes *this* way when the EHR at the teaching hospital has me enter it the other way?
• Are there additional contraindications?
• When was the patient’s last MRI?
• I’m running behind, but I still need to enter this script.

Is it any wonder that it’s not a simple task to make an EHR that a doctor will consider usable? Not impossible, but certainly a challenge.

User Centric will be at HiMSS, Chicago! Booth #3382 They’ll be demonstrating how eye tracking can be utilized to uncover opportunities to improve user interfaces. No, I don’t have any financial connection with them, but eye tracking is really cool technology. Plus, I’m happy to support anyone that I think can make a difference when it comes to making EMR software more usable.

John over at Chilmark Research has a really good find on his blog. He quotes the new head of ONC, David Blumenthal, from an article in the New England Journal of Medicine (NEJM) where Blumenthal talks about the certified EHR requirement in the HITECH act. Here’s the quote:

ONCHIT currently contracts with a private organization, the Certification Commission for Health Information Technology, to certify EHRs as having the basic capabilities the federal government believes they need. But many certified EHRs are neither user-friendly nor designed to meet HITECH’s ambitious goal of improving quality and efficiency in the health care system. Tightening the certification process is a critical early challenge for ONCHIT.

I find it really interesting how two people can take the same quote different directions. Chilmark Research gives a nice little rant about how you can’t certify usability, quality and efficiency in an EHR. I agree with him on most points and I definitely agree that the market is much better at these three items than some government certification body.

However, I don’t feel like this was what Blumenthal meant in the above quote. I don’t think Blumenthal was trying to say that the certification would need to certify user-friendly, quality and efficient EHR software. Instead, I see the above quote meaning that the current CCHIT certification isn’t good enough, because it has certified a bunch of unusable EHR (a topic we’ve talked about many times before). Sounds to me that Blumenthal is making a case for why the government shouldn’t use the CCHIT certification. At least not in its current form. Essentially Blumenthal is saying that CCHIT isn’t good enough to meet the goals of HITECH.

This seems like a ray of hope for myself and others who think that selecting CCHIT certification as the certified EHR requirement of the HITECH act is the worst decision the government could make. Albeit still just a ray.

What Blumenthal means about “tightening the certification process” is up for debate. He could mean something like what John from Chilmark research describes. Basically some convoluted method of measuring usability, quality and efficiency of an EHR system. Or it could mean that the certification process will need to be tightened so that unneeded requirements are removed and it gets cut down to what will help an EHR achieve the ambitious goals of the HITECH act.

Of course, in the end the certified EHR criteria will probably land somewhere in between. However, this quote did give me some hope that Blumenthal realizes the impact that it will have on EHR adoption if many of the currently unusable certified EHR gain wide adoption thanks to the $18 billion in EHR stimulus money.

I do think John from Chilmark Research does make a nice conclusion to his post:

Suggesting that we tighten the certification process is heading in the wrong direction. Instead, we need to actually relax the certification process to encourage innovation in the HIT market allowing developers to create solutions that will truly provide value to their users while concurrently meeting the broader objectives of delivering better care and better outcomes. Creating light certification criteria and focusing more on what outcomes we wish to see occur as a result of broad HIT adoption is where Blumenthal and his staff need to focus their energies.

A very passionate poster on EMRUpdate recently found something anyone familiar with CCHIT already knew. It’s just really interesting that CCHIT seems to have put this in writing for all to read. Unfortunately, far too many doctors haven’t read this very important information. I’ll do my part and share it here:

“CCHIT, in fact, recognizes some of its own limitations. Its Certification Handbook states: Our criteria at this point can only represent broad, basic capabilities, and . . . these may prove insufficient for some practice specialties, or may be inappropriate or excessive for others; . . . our criteria do not assess product usability, implementation service, product maintenance, technical and application support; and other facts.”
Source: Finding a Cure: The Case for Regulation And Oversight of Electronic Health Records Systems, Harvard Journal of Law & Technology 2008 vol. 22, No. 1, by Hoffman and Podgurski, p. 133-4: