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Thursday, November 13, 2014

The AMA on Usability - "the design and implementation of EHRs do not align with the cognitive and/or workflow requirements and preferences of physicians within and across specialties and settings."

Good paper.
The AMA recognizes that not all EHR usability issues are directly related to software design. Software design varies greatly among vendors and specific organizations that often customize EHR functions. For example, some EHR usability issues are a result of sub-optimal implementation, required by the practice itself or part of an organizational policy (e.g., risk management, institutional liability concerns or inadequate training of users). Other issues may be related to regulatory requirements (e.g., state and federal regulations such as an overly prescriptive MU). EHR usability issues may also be due to suboptimal practice workflow processes that have been incorporated into EHRs. Workflow analysis, collaborative end-to-end workflow design and associated training are very expensive and are often neglected in projects with limited budgets and strict timeframes to meet MU requirements (i.e., deadlines to receive subsidies and/or to avoid penalties)...
Eight EHR Usability Priorities
Enhance Physicians’ Ability to Provide High-Quality Patient Care. Effective communication and engagement between patients and physicians should be of central importance in EHR design. The EHR should fit seamlessly into the practice and not distract physicians from patients.
Support Team-Based Care. EHR design and configuration must: (1) facilitate clinical staff to perform work as necessary and to the extent their licensure and privileges permit and (2) allow physicians to dynamically allocate and delegate work to appropriate members of the care team as permitted by institutional policies
Promote Care Coordination. EHRs should have enhanced ability to automatically track referrals and consultations as well as ensure that the referring physician is able to follow the patient’s progress/ activity throughout the continuum of care.
Offer Product Modularity and Configurability. Modularity of technology will result in EHRs that offer flexibility to meet individual practice requirements. Application program interfaces (APIs) can be an important contributor to this modularity
Reduce Cognitive Workload. EHRs should support medical-decision making by providing concise, context sensitive and real-time data uncluttered by extraneous information. EHRs should manage information flow and adjust for context, environment and user preferences.
Promote Data Liquidity. EHRs should facilitate connected health care—interoperability across different venues such as hospitals, ambulatory care settings, laboratories, pharmacies and post-acute and long-term care settings. This means not only being able to export data but also to properly incorporate external data from other systems into the longitudinal patient record. Data sharing and open architecture must address EHR data “lock in.”
Facilitate Digital and Mobile Patient Engagement. Whether for health and wellness and/or the management of chronic illnesses, interoperability between a patient’s mobile technology and the EHR will be an asset.
Expedite User Input into Product Design and Post-Implementation Feedback. An essential step to user-centered design is incorporating end-user feedback into the design and improvement of a product. EHR technology should facilitate this feedback. 
As one would expect, Jerome Carter, MD is all over this on his excellent EHR Science blog.
AMA Conclusion: The Road Forward

According to the AMA Rand study, the single largest driver of professional satisfaction is the physician’s perceived ability to deliver high quality care to patients. The AMA believes that if the above priorities were implemented in the EHR design, it would (1) enable physicians to deliver such care, (2) improve physician experience with the technology, (3) increase physician productivity and (4) reduce administrative costs. Aside from these eight EHR usability priorities, the AMA believes that additional research is needed to determine how EHR use promotes or inhibits high quality care. It is essential to better understand the cognitive needs of physicians and how EHR products can meet them, identify evidence that outlines the benefit tools that support decision-making and explore how EHRs influence the patient encounter. All are opportunities for research that would benefit the advancement of EHR technology. Finding evidence of what works and what doesn’t work will be critical to improving EHRs.
That's all fine and necessary, and I guess this being the AMA, the physician-centric focus is inevitable. But, there are larger necessary policy (Fee For Service?) and organizational paradigm changes ("Talking Stick?") going far beyond technology that, if left largely unaddressed will likely significantly hinder or negate any UX/workflow advances.

Consider that a typical complete ONC certified ambulatory EHR system may house between 3,000 to 4,000 RDBMS variables under the GUI hood, and a typical "moderately complex patient" encounter (e.g., a 99213) may require finding/accessing, viewing, updating/editing, and evaluating/synthesizing many hundreds of them (or more; e.g., longitudinal "flow sheet" trend data and/or specialist findings) as part of the SOAPE process, all in a severely constrained period of time.

Do a workflow/click-thru time consumption thought experiment. See also my blog post update of August 8th, 2010.

Dr. Carter on the AMA paper:
...Building systems with features in line with the AMA framework requires knowledge about clinical work and models of how information is used by clinicians, neither of which  currently exists.  The same is pretty much true of clinical systems architectures.   Yes, EHR systems exist, but no one knows the ideal architecture or component design strategy to achieve robust, secure, interoperable, collaborative systems.  In other words, there is no blueprint, and there is no source to consult that explains how to create such blueprints.  To anyone who thinks that tweaking current systems is the way to go, I say: Remember what happened with MU Stage 2 certification.

Alteration of current products is not likely to result in systems that reflect the AMA’s framework.  The time, money, and effort required to convert current EHR systems into clinical care systems that support clinical work is likely greater than most companies would care to expend (see Is the Electronic Health Record Defunct?).  Therefore, I expect the next generation of systems will come from new companies and not current market leaders (see Disruption in the EHR Market: Will Anyone See It Coming? ).

Building usable, interoperable systems that intimately support clinical work will require creativity, research, patience and, I imagine, some amount of luck (or serendipity if you prefer). In other words, the road from here to there is not on a map.   There are a lot of challenges, so let’s acknowledge this and get going.  Those blueprints will not design themselves.
apropos of all of the foregoing, is the data acquisition/assimilation burden likely to grow?
IOM Panel Identifies 12 Social, Behavioral Measures for EHRs
Thursday, November 13, 2014

On Thursday, the Institute of Medicine released a report detailing 12 social and behavioral factors it feels should be included in electronic health records, FierceEMR reports...

Those measures are:
  • Alcohol use;
  • Depression;
  • Educational attainment;
  • Financial resource strain;
  • Intimate partner violence for women of reproductive age;
  • Median household income;
  • Physical activity;
  • Race/Ethnicity;
  • Residential address;
  • Stress;
  • Social isolation; and
  • Tobacco use.
In the report, the committee noted that adding these domains to EHRs could put more pressure on providers. However, the authors also noted that patients could report the data via their personal health records or a computer, which would not greatly disrupt providers' workflow.

In addition, IOM said the health benefits of including these domains outweigh the administrative burden (Gold, Politico Pro, 11/13)...
Certain to be controversial, for a variety of reasons. And, what about the burgeoning accretion of "omics" data?

For one thing, I would not be so sanguine about "minimal workflow disruption."

Hmmm... tangentially, how about this?
EHRs are increasingly common and contain detailed data about patients’ encounters with the health system — data that have tremendous value for health care improvement efforts. These same data also provide opportunities for marketing. Using EHR data, it’s possible to determine the clinical and demographic characteristics of patients within a given practice and the circumstances under which physicians choose particular treatments, even when information is anonymized at the patient level. Although most large EHR vendors do not sell data to third parties, some have made information sales part of their business model. For example, Practice Fusion offers its EHR software to physicians free of charge but generates revenue by selling access to anonymized clinical data derived from more than 80 million patient records.

EHRs can also be used for direct marketing to physicians at the point of care, through features such as banner ads, industry-sponsored clinical resources, and tools for requesting samples, article reprints, and other items — a role previously filled by sales representatives. Unlike traditional forms of advertising, digital technologies (e.g., MD On-Line) enable tailoring of advertisements to individual physicians on the basis of data from clinical encounters. Some marketing platforms (e.g., Physicians Interactive) integrate advertising at the point of prescribing with “eCoupons” that are generated in real time and transmitted directly to pharmacies when physicians select promoted medications.
From NEJM, by way of The Incidental Economist.


From Kaiser-Permanente Physician Leader:

A culture of doctors over-treating as a defense mechanism against medical liability should be replaced by a culture of patient-centered care.

The Dallas/Fort Worth Healthcare Daily ran a fascinating excerpt from the Steve Jacob’s book So Long, Marcus Welby, M.D.* The excerpt contained some very interesting assertions and statistics. For example: 
  • Consultant PwC, relying on that Congressional Budget Office (CBO) report, estimated that malpractice insurance and defensive medicine accounted for 10 percent of total health-care costs. A 2010 Health Affairs article more conservatively pegged those costs at 2.4 percent of healthcare spending. 
  • In a 2010 survey, U.S. orthopedic surgeons bluntly admitted that about 30 percent of tests and referrals were medically unnecessary and done to reduce physician vulnerability to lawsuits. 
  • A 2011 analysis by the American Medical Association found that the average amount to defend a lawsuit in 2010 was $47,158, compared with $28,981 in 2001. The average cost to pay a medical liability claim—whether it was a settlement, jury award or some other disposition—was $331,947, compared with $297,682 in 2001. 
  • Doctors spend significant time fighting lawsuits, regardless of outcome. The average litigated claim lingered for 25 months. Doctors spent 20 months defending cases that were ultimately dismissed, while claims going to trial took 39 months. Doctors who were victorious in court spent an average of 44 months in litigation. 
  • A study in The New England Journal of Medicine estimated that by age 65 about 75 percent of physicians in low-risk specialties have been the target of at least one lawsuit, compared with about 99 percent of those in high-risk specialties. 
  • According to Brian Atchinson, president of the Physician Insurers Association of America (PIAA), 70 percent of legal claims do not result in payments to patients, and physician defendants prevail 80 percent of time in claims resolved by verdict.
My comment:
Very interesting. will have to cite this on my blog. One area I feel gets insufficient attention is that of what I call “workplace psychosocial toxicity,” e.g., “bully culture” (or just the more prevalent FUD environments). I argue that all of the Health IT and process QI (my specialty) in the world may be negated by chronically toxic workplaces where one speaks truth to power at one’s peril. It’s a sad irony that many healthcare workplaces are anything BUT “Just Cultures.” I have examined this issue at great length, breadth, and depth. The chronically psych-toxic workplace issue is ultimately a patient safety issue.


We have superb doctors in the United States. These exceptionally well-trained men and women understand that they are crucial patient advocates. Physicians must accept the responsibility of guiding our nation to a better health care delivery system, but the pathway forward, amid jarring changes in our health care system, is not always clear.
The doctor crisis is the convergence of a complex amalgam of forces preventing primary care and specialty physicians from doing what they most want to do: put their patients first at every step in the care process every time. Barriers include overzealous regulation, bureaucracy, the liability burden, reduced reimbursements, and more. As a result, many physicians hold deeply negative views of the medical profession.
Solving the physician crisis is a prerequisite to creating a health care system that is patient-centered, safe, equitable, accessible, and affordable. And we believe that freeing doctors to concentrate on providing excellent care is, by definition, patient-centered.
Cochran, Jack; Kenney, Charles C. (2014-05-06). The Doctor Crisis: How Physicians Can, and Must, Lead the Way to Better Health Care. PublicAffairs. Kindle Edition.
We'll see. Looks like an interesting read.


OK, this is funny. Props to


 in light of #GruberGhazi...


More to come...

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