Comments (6)


February 3, 2010

When it comes to EHRs, design matters

I’ve been writing a lot about social media these days if you haven’t noticed.

It isn’t because I’m fascinated with the actual tools, many of them will have disappeared in the next couple of years. Rather, it is one of the most poignant examples of the incredible participation rates that great user design can induce. The possibilities of how this can transform government and key public issues have me mesmerized.

No public issue is as front and center these days as health care. Leland Berkwits, M.D. wrote into questioning the conclusions from a study conducted by a group of educators at the University of Illinois at Chicago College of Medicine.

The study was to answer the question: “Does the medical-school curriculum adequately prepare students to diagnose and treat patients using an electronic health record?”

The conclusion Dr. Berkwits questioned?

Rachel Yudkowsky, associate professor and director of the university’s clinical performance center and part of the group that conducted the study concluded that, “What we found is that the students all looked in the medical record, but the majority of them didn’t find the information. We might need to work with the students on how you scan the record because the record is complicated.”

Dr. Berkwits in his letter brings up a compelling point which is that conventional EHRs, not the physicians or students are the problem. He noted as a practicing physician for the past 17 years and having used 5 different systems, none of them were “intuitively easy to use”.

It seems that those that conducted the study and Dr. Berkwits would agree on one issue. Whether it is the EHR or the training of the physician, the disconnect does lead to more user errors such as medication errors that could harm patients.

Aren’t these incidents EHRs are suppose to reduce?

In the interest of fewer errors and achieving the adoption rates needed around meaningful use, it behooves us to make EHRs more intuitive to use. It is much easier and predictable to mold technology around the user than to try to change human behavior.


  • By Leland Berkwits, MD - 6:23 PM on February 4, 2010  

    Thanks for reading my comments… just for the record, last I looked, I was of the male sex. So you may wish to change your she’s to he’s.

    Also… for what it is worth, I do believe that Rich Internet Applications will help in making EHR’s more usable, however, there must be best practice guidelines for user interface design.

    An simple example, a listbox with 40 entries for drug dosing frequencies is highly error prone and can cause medication errors. This is completely unacceptable in a medication order entry screen. (This user interface faux pas exists in my current EHR – which I am in the process of deinstalling.)

    Finally, any web based (ASP/SaaS) application has to have strict performance criteria with respect to response. The medical history and exam entry process is extremely transaction intensive. While the portal for web surfing and providing medical care may be the same in these systems, response latencies are extremely critical in the latter activity. This means that most internet based system for the medical environment require at a minimum, caching of a significant amount of the front end code to serve the application locally on the client machine. A simple .NET implementation may work with a local server, but once data is being routed through the internet, performance is completely dependent on transmission latency and lost packets and data bandwidth becomes a critical issue.

    Leland Berkwits, MD, MSEE

  • By Gutschein - 11:36 AM on February 7, 2010  

    Hi all,

    thanks for share this interesting article. I knew now more usefully things about EHRs.
    Many Thanks and Regards from Germany,

    P. Gutschein

  • By Steve Daviss MD - 5:02 PM on February 7, 2010  

    This relates to both UI and the way EHRs are used. Not only can one not find the info that is there (somewhere), but also there is relevant patient info in other EHRs or other systems that cannot connect with the EHR being used at the time. A group of us (SpeakFlower) are proposing a model of interconnected systems using open standards for transport and security of health information, like a browser aggregating content from multiple servers, that would permit patients to access all their health information with one portal, and control who can access and annotate different parts of their data. Including friends and family, as well as doctors, hospitals, etc, thus permitting a social network to form around health issues. This would allow patients to invest more of their time and energy into their health, in the same way that and others have allowed people to organize around their finances.

    Web-based EHRs and PHRs will make it easier for the clunky, awkward, non-intuitive systems we now have to evolve more rapidly into intuitive, user-friendly tools to manage our personal health.

  • By Loni Kao Stark - 8:07 AM on February 12, 2010  

    Dr. Berkwits,

    LOL, I’ve corrected your sex.

    Apologies also for taking some time to unclog the spam filter on this blog and discover your comment along with 2 others among them.

    I absolutely agree with you on RIA design guidelines for EHR and for any system, especially ones that impact decision which can be critical to the outcomes of a patient’s treatment. (Speaking about this and imagining myself as that patient.)

    You seem to have thought a lot about this issue, I’d like to hear more. I’ll shoot you a note.

    In meantime, have a great weekend!

  • By Loni Kao Stark - 8:23 AM on February 12, 2010  

    Your welcome!

    I found the article and perspectives very timely and relevant as we all grapple with ‘meaningful use’ and what it means to improve quality of care.

    Data integrity is one thing, but ultimately health care is delivered by people and the information needs to be accurately interpreted by clinicians, nurses and sometimes even the patient when they must make trade-offs between different treatment options.

    Since my original post on this discussion, others have also chimed in.

    Dr. David Hager writes (and I really hope he doesn’t mind me quoting him here, but I could not put it any better myself):

    “EHRs are, first, for clinicians to use in order to provide care to patients. I think that point may be lost somewhere. They are not primarily for administrators or politicians or software engineers or geeks or auditors.

    An EHR must be intuitive, like a well-designed marketing Web site, and do things with data we didn’t even know we wanted, but won’t want to relinquish. It should cause no more effort than our existing written work flow, and not slow us down as we see our load of patients. It should conform to our idiosyncrasies—and not the other way around.

    Ultimately, if clinicians don’t buy into and actually want to use an EHR, the whole concept will dwindle, political pressures notwithstanding. The current swell of interest fueled by temporary money will end in disuse atrophy. We have to want to use an EHR because we find it has become an indispensable tool—so that we can’t imagine seeing our patients without one, any more than a family doc can imagine getting by without a stethoscope.”

    Hear, hear!

  • By Loni Kao Stark - 8:35 AM on February 12, 2010  

    Dr. Daviss, Good points. Good user experience extends beyond UI, especially in mission critical areas like health care.