Healthcare // Electronic Health Records
Commentary
7/24/2014
09:06 AM
Mony Weschler
Mony Weschler
Commentary
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EHR Vendors: Step Up Your Game

Electronic medical record vendors need to take a clue from video game design. It's time to deliver intuitive, simple to learn, and easy to use EHR technology.

10 More Robots That Could Change Healthcare
10 More Robots That Could Change Healthcare
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Dear Heath IT Vendors: The time is now. I urge you to open your platforms, enhance your APIs, encourage sharing of data, and adopt standards. Let's foster a new era of innovation.

As chief IT strategist for Montefiore Medical Center, a New York-based academic medical center and university hospital for Albert Einstein College of Medicine, I focus on understanding our clinical and business needs and deploying system enhancements that provide practical, targeted IT solutions. I've been doing this for 25 years, but we still face many of the same problems we did a quarter-century ago.

Hospital systems are investing hundreds of millions of dollars in an electronic medical record (EMR) system that physicians and other eligible providers are not flocking to use. Why is this the case? Why do some clinicians complain the system gets in the way of treating their patients? Why is it difficult to train clinicians on how to place an order or print a barcode for a blood draw? From a patient perspective -- and as consumers of what has been referred to as the world's most expensive healthcare system -- is it too much to ask for access to a longitudinal medical record?

Why do we put up with it? This is particularly baffling when after a day of evaluating how we can leverage technology to improve patient experiences, I come home to find my son playing video games that put to shame almost any technology I've seen focused on engagement.

[Another call for reform: Standardize EMRs, For Security & Safety's Sake.]

Let's take gaming as an example. The worlds our kids manipulate are far more complicated and intense compared to placing an order for a lab or radiological procedure. Yet even the most inexperienced game player can operate these worlds without hours of training or reading any manuals. The simple reason is that gaming designers spend a great deal of time sharing insights and thinking about the real-life context in which people play the game before the design process even begins. They understand it is all about user experience, and usability will always trump the best and fastest technology. We should be mirroring this experience.

Now is the time to usher in a new era of innovation. Healthcare is changing. We are moving to a fee-for-performance model that encourages a collaborative process involving public- and private-sector stakeholders and shared decision-making between patients and providers. The need to disclose relevant health and population data seamlessly is critical. In an accountable care organization (ACO), it's paramount that we have access to the complete patient record.

To our vendors' credit, they have implemented more systems, incorporated more security, and delivered more mandated functionality than ever before. Still, with all the advancements, the user experience lags. It is time to learn from other industries and incorporate technology from outside traditional healthcare IT. It is a necessity for us to deliver an exceptional user experience and the interoperability required for us to improve quality and reduce the cost of healthcare.

Imagine the possibilities if EHR vendors transform their closed and proprietary systems into open platforms, similar to the iTunes store or Google Play, so startups and seasoned vendors could provide input and build upon what exists. The opportunity would quickly attract the attention of many healthcare incubators and accelerators that have sprung up across the country and across the world. Such an open EHR platform has the greatest potential for transforming healthcare, in a way similar to what antibiotics did for medicine.

I have seen more healthcare IT accomplishments during the past five years than the preceding twenty, so I am optimistic we can begin to learn and take advantage of the progress made in other industries.

We must get moving though! Advancements and innovations in technology are here -- wearable biosensors, mobility, social media, and, yes, Google Glass are already entering operating rooms. This is just the beginning. What is to come in the next 20 years seems to be limited only by antiquated barriers and our imaginations. Don't you agree?

The opinions expressed here belong to Mony Weschler and do not necessarily reflect those of Montefiore Medical Center.

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Mony Weschler, Chief Applications Strategist and Architect for Applications Technology Services at Montefiore Medical Center, has 25 years of clinical IT informatics and management experience within leading academic healthcare systems. His work focuses on improving patient ... View Full Bio
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shihjay2
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shihjay2,
User Rank: Apprentice
7/31/2014 | 10:56:53 PM
Unfortunately, EHR innovation will be painfully slow the way things are going...
Mony,
I appreciate your enthusiasm and optimisim regarding EHR innovation.  I wish the same, but as a physician as well as an open source software coder (or hacker) who developed his own homegrown EHR (NOSH ChartingSystem), I have serious concerns about the trajectory of the EHR and Health IT market.  You correctly asked and answered the question of why physicians are not adopting EHRs and yes, it is all about usability.  I wrote a blog post (http://noshemr.wordpress.com/2013/09/07/omg-why-the-user-experience-for-an-ehr-is-everything/) about this and I feel that most EHR vendors would care less about physician's idea of workflow and usability because most EHR's are designed from a framework based on billing and administrative workflows rather than patient care, espeically in the outpatient realm (which is quite different from a hospital or academic medical center).  To most physicians, even those like me who are tech savvy, this is a difficult concept to reconcile and is quite disruptive.  Until an EHR adequately addresses clinical workflow usability (which I don't think any really do), physician adoption and participation will be suboptimal.  Unfortunately (this is where I am pessimistic), those who have the financial means to purchase or develop an EHR (ie adminstrators) are those that don't have the clinical expertise to understand these usability, user-interface issues, and subsequently enough agitation to innovate there. 
 
On top of that, the Meaninful Use initiatives have significantly altered the EHR market where, intentionally or not, we are starting to see EHR market consolidation with only a few major player.  This will have negative effect on physician's voices being heard to address usability issues and innovation will likely be stiffled since there is no incentive to these big EHR vendors to change their tune or innovate for innovation's sake.
 
That's why I developed my EHR, first as an open source licensed web-based project, to hopefully educate and encourage physican input in continuously improve it, to see what would happen if an EHR was built from a clinician's point of view...already, I believe it's quite different than the traditional systems.  It's also open in the sense it adopts open standards (like Blue Button Plus for C-CDA generation and parsing) and in the future, clearly documented API's will be developed so that data can be shared securely between other systems if one so chooses.  I also deliberatly chose to avoid certification for MU for the reasons that the certification requirements are antithetical to clinician usability.  Yes, it's a huge undertaking and goes pretty much against where things are going in the EHR and Health IT realm, but I believe clinicians absoultely need to be involved in the process, otherwise, it's not much of a "health" record with meaningful data for the clinician.  But who knows?
asksqn
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asksqn,
User Rank: Ninja
7/28/2014 | 5:18:06 PM
A pleasant fiction
excerpt 

>>Imagine the possibilities if EHR vendors transform their closed and proprietary systems into open platforms<<

/excerpt

I'm sure this sentence alone is making EHR vendor CEO heads explode.  CEOs aren't exactly the sharpest tool in the shed - many of them can barely use email.  Suggesting that their proprietary systems (which = cha ching in their minds) is tantamount to giving away the system for FREE.  Sorry.  Ain't gonna happen.  The entire industry would have to undergo a profound paradigm shift and I don't see that happening anytime soon.  It's a pleasant fiction, however.
mweschler107
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mweschler107,
User Rank: Apprentice
7/28/2014 | 4:40:29 PM
Re: Want to change the game? Rethink who's eligible to play.
Thank you for your response. 

Having been a hiring manager for most of my career I recommend that all candidates ignore the past healthcare experience requirements for most applications. I myself got into healthcare straight out of college without any healthcare IT experience. Most skilled managers will look beyond the healthcare requirements if there are other solid skills listed in the CV. I have hired many candidates that had no healthcare experience but I sensed a willingness to learn and that the individual would be a good team player. The trend is definitely changing and it is opening up and hiring the best people in healthcare IT! This is good new indeed for the industry and for the new talent.

Warm Regards.

-Mony
Jeff Jerome
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Jeff Jerome,
User Rank: Ninja
7/25/2014 | 10:58:28 AM
Re: Usability of EHRs And if you don't someone else will
@ Henrisha - Your comment about customer loyalty is very true for EHR and frankly and software of professional services provider.  Customer service is not a department it is a company philosophy.  And for a healthcare provider to jump ship there has to be a very compelling reason.  With that said I am going to ask my customer what drove them to take on that change from one provider to another.  It took them over two years and untold millions of dollars to achieve this goal.  So there was something big that made that happen.
Henrisha
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Henrisha,
User Rank: Strategist
7/25/2014 | 1:26:55 AM
Re: Usability of EHRs And if you don't someone else will
EHR vendors, and all other vendors for that matter, shouldn't bank on customer loyalty. First and foremost, what matters is the service and support customers get. If you fail on any point, they will switch to another who can give them what they need.
Jeff Jerome
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Jeff Jerome,
User Rank: Ninja
7/24/2014 | 10:50:40 PM
Re: Usability of EHRs And if you don't someone else will
Personally I have seen companies switch EHR vendors and that is no small commitment.  And from usability point of view if the vendor does not make the application easy to use then customers will find alternatives.  And for traditional software companies who get usability they will find a way to make the interface more attractive.  Plus there are new vendors coming on line that offer EHR as a Service, practice Fusion for one.  The typically cater to smaller practitioners but this too could change.
ShelleyAdams
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ShelleyAdams,
User Rank: Apprentice
7/24/2014 | 2:18:48 PM
Want to change the game? Rethink who's eligible to play.
The minimal requirements for every health IT job listing I've read during the last 18 months contain an item that automatically disqualifies the vast majority of tech developers and interface designers:
X years [or months] experience in healthcare [sometimes adding or related industry]

No doubt, healthcare is different. Many industries demand a focus on safety with respect to potential biological, chemical, physical, or radiologcal hazards or an awareness of laws related to use of chemicals, information privacy, or professional malpractice. Healthcare demands all of these simultaneously, often with lives at stake.

In light of such demands, wouldn't it be more sensible to hire the best IT professionals regardless of past employment setting—to prefer, but not require, healthcare experience?

Mr. Weschler speaks of his optimisim that healthcare IT ...can begin to learn and take advantage of the progress made in other industries. Organizations seeking to do this—and to do it efficiently—will need to welcome IT professionals from outside healthcare sector.
UsabilityPeople
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UsabilityPeople,
User Rank: Apprentice
7/24/2014 | 9:41:05 AM
Usability of EHRs
Thanks so much for posting this article!!

We totally agree with the majority of the points that you make and would like to add the following:

Adopting User-Centered Design (UCD) methodologies saves money (10-100x ROI)

Adopting User-Centered Design methodogies in Healthcare can save lives - see 

http://www.healthcareusability.com/article/medical-experts-emphasize-role-health-it-patient-safety

The ONC Meaningful Use stage two certification required that EHR vendors describe their UCD practices and provide a summative usability test as part of their submission.  A large number of these vendors have provided filler text (copied and pasted from NIST documentation) and less than what should be acceptable studies (We've seen vendors report on summative studies with a single participant, and that participant was an employee of the EHR vendor!)

The HealthIT market is about 10 years behind the enterprise software market, which is about 5 years behind the consumer market.  Given the amount of money that is involved in healthcare, and the potiential for this technology to extend and improve the quality of life for so many, it is a shame that the industry is so far behind.

We are doing all that we can to help, by conducting summative studies, helping EHR vendors with design issues, presenting papers on usability at conferences, engaging on social media,etc.  We all need to work together to solve this.  Join us after all, Usability starts with YOU.

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