One of my favourite sources of information on the health IT market is HISTalk, particularly their daily round-up of health IT news. In this morning’s summary, the editors cited Dr. Robert Pearl, CEO of the Permanente Medical Group, and his reasons why health IT is not “widely embraced”:
- Developers focus on doing something with a technology they like rather than trying to solve user problems, such as jumping on the wearables bandwagon despite a lack of evidence that they affect outcomes.
- Doctors, hospitals, insurance companies, and patients all feel that someone else should pay for technology they use.
- Poorly designed or implemented technology gets in the way of the physician-patient encounter.
- EHRs provide clinical value, but slow physicians down.
- Doctors don’t understand the healthcare consumerism movement and see technology as impersonal rather than empowering.
The editors also offered their own thoughts on this topic, citing the following impediments to health IT adoption:
- People embrace technology that helps them do what they want to do. Most healthcare technology helps users do things they hate doing, like recording pointless documentation and providing information that someone else thinks is important.
- Technologists assume every activity can be improved by the use of technology. Medicine is part science, part art, and technology doesn’t always have a positive influence on the “art” part.
- Healthcare IT people are not good at user interface design and vendors don’t challenge each other to make the user experience better. Insensitive vendors can be as patronizing to their physician users as insensitive physicians can be to their patients.
- Technology decisions are often made by non-clinicians who are more interested in system architecture (reliability, supportability, affordability, robustness, interoperability) than the user experience, especially when those users don’t really have a choice anyway.
- Hospital technology is built to enforce rules and impose authority rather than to allow exploration and individual choice. Every IT implementation is chartered with the intention of increasing corporate control and enforcing rules created by non-clinicians. That’s not exactly a formula for delighting users.
What are your thoughts? Do any of these reasons ring true for you? Would you challenge any of them as incorrect? Do you have any reasons of your own to add?
Regular readers of my blog and the articles that I write for several publications will know that I have considerable concerns about the usability of physician office health IT systems (typically referred to as EMR in Canada and EHR in the US). The US Office of the National Coordinator for Health IT (ONC) shares my concerns [or, perhaps, I share their concerns :)] and has funded the US National Institute for Standards and Technology (NIST) to provide advice on how to improve the usability of EHR software.
According to a post on MedHealthWorld, NIST has released two publications related to EHR usability design and testing:
I am huge fan of user centered design. I have personally witnessed the level of user acceptance of the software produced using this approach. By actively engaging users throughout the design and development process, the likelihood of user acceptance is greatly increased. Indeed, I have seen users literally nagging developers as to when the software that they helped design would be ready for them to use.
I have written in several publications (including this blog) about increasing concerns regarding the usability of electronic medical record software (aka electronic health record software in the US). At a recent conference I was pondering my position on this matter as I listened to one of the speakers when I suddenly released that I was one of the few people in the room who wasn’t using pen and paper to take notes (I was using my iPad). Interesting, I thought to myself. I wonder if these same people type up their notes when they get back to the office, either to share with colleagues or perhaps even to enter into a CRM system of some sort. If they don’t type them up, how often do they refer to them? Do they ever try to search for notes they took in the past?
While it might be stretching an analogy, there are some similarities between the process of taking notes at a meeting and the recording of patient data during a medical exam. Perhaps the same reasons that we are more comfortable using pen and paper are similar to the reasons that physicians offer when expressing their reticence to use EMR software. At the very least, making the change to from analog to digital note taking involves letting go of an approach with which we are very comfortable and that we have used for a very long time, just as it for physicians making the change from paper to electronic records.
Is it possible that we are asking physicians to “Do as we say, not as we do?” I can tell you from firsthand experience that trying to go paperless in my day to day business operations has not been without its challenges. My recent foray into getting rid of paper notes is not the first time that I have tried to do so. Over the past two decades I have tried several different technologies, each with limited success. The purchase of my new iPad prompted me to try again and I think that I might actually succeed this time.
So, who else is going to join me and do what we are asking our clients to do?
I was doing some work around our condo this weekend and needed a few supplies. I walked over to our neighborhood hardware store, a small store crammed floor to to ceiling with a little bit of everything one might need for home repairs, to pick up these supplies. I love this store … it reminds me of the hardware stores I used to visit when I was a kid. They still sell nuts and bolts and other small items individually. You pick what you need from a bin, write down the bin # and take it to the cash to pay.
I picked up 6 dry wall anchors costing $0.15 each along with several packages of other items that I needed. The cashier rang up my purchases and told me that I owed her $23 and change. I thought for a moment, looked at my purchases, and suggested that the amount seemed rather high. We reviewed the bill and discovered that I had given her the wrong bin # for the wall anchors. She was charging me for 6 cup hooks, not 6 wall anchors.
As I was walking home I thought about the encounter for a few moment. The computer-based cash register clearly displayed the description of each item I purchased along with the price. The cashier did not confirm that was she rang in matched what I had purchased and then proceeded to blame me for giving her the wrong bin #! What if the encounter had been a medical one? Just because a computer is involved doesn’t mean that we should assume that the information presented is correct. Human judgment still plays a critical role in any interaction involving a computer. We need to always consider the human factor and provide appropriate mechanisms for information review and confirmation of all actions.
One of the topics that seems to getting more attention as we strive to push health IT more into the mainstream is usability. Prior to fully immersing myself in the health sector seven years ago, I worked for a major Canadian system integrator and had an internal usability team reporting to me. This team joined the company through the acquisition of a small but innovative Canadian Internet consulting company and we struggled at times to demonstrate its value to the rest of the organization. In working with this team to figure out how best to sell their services to our clients, I learned a lot about usability and the importance of taking usability into account during the design stage.
I came across what I think is a succinct summary of why usability is so important to the health sector. Of particular interest in this article is the table listing five “usability myths” and corresponding “usability facts”. One of myth in particular resonated with me – “Usability is entirely a matter of subjective opinion”. As the article points out, this rather commonly held view is completely false and there are indeed a variety of criteria that can be applied to assess usability.
I believe that one of the greatest challenges that we have to realizing the full benefits of digitizing our health system is usability. As the article points out, a report published by the National Research Council (“Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions“) points out that ““…the nationwide deployment of health IT will not be sufficient to achieve the vision of 21st century healthcare, and may even set back the cause…. [Success] will require greater emphasis on providing cognitive support for healthcare providers.” Failure to address cognitive usability is a very real possibility, one that must be addressed more aggressively in my view.