A critical issue in biomedical informatics is electronic health record (EHR) usability. EHR software organizes much clinical practice, with many clinical users spending half their day interacting with such software. Inefficiencies imposed by poor EHR usability are magnified across hundreds of thousands of clinicians daily. For reasons included below, major advances in alleviating current clinician frustration with EHR usability will likely require intensified focus on supporting team-based medicine.
One important group of incompletely satisfied clinicians are physicians. Physicians despise those aspects of EHR use that they perceive as "data entry." Yet, the capture of structured data is essential to clinical decision support, quality monitoring, and billing. Structured data have traditionally included orders, diagnoses, and allergies, but increasingly include capture of patients' review of systems, tobacco and alcohol use, and templated clinical documentation. No amount of user-friendly methods will disguise the fact that the EHR is increasingly structuring physician-patient interactions.
In our local health care system, primary care physicians coordinate teams to manage the health care needs of panels of patients. The goal is to allow physicians to focus on those aspects of medical care that require their expertise. To such ends, the American Medical Association has recommended that future EHR design allow clinical staff to assume duties "to the extent their licensure and privileges permit," as well as "allow physicians to dynamically allocate and delegate work to appropriate members of the care team." Individual practices must have near-complete flexibility to allocate clinical work based on factors such as ratios of physician to non-physicians, levels of training and experience, personal preferences, and even whether someone calls in sick on a particular day. The EHR would then ideally weave together these parallel team-based efforts, verifying that all aspects of medical care have been addressed by the end of the patient visit.
With robust EHR support, non-physicians could undoubtedly appropriate work from physicians related to structured data capture and clinical documentation, but with automated standing order protocols, appropriation might even extend to domains such as preventive care and chronic medication titration. For example, a future physician might order the "routine preventive care protocol," "hypertension protocol," or "anticoagulation protocol" for a patient, with EHR-based software subsequently generating automated standing orders for nurses or similar staff. Through the EHR, physicians could be fully aware of these parallel efforts during patient encounters, responsible for reviewing periodic summary reports to ensure quality, and alerted in the event issues arise.
EHR usability is defined as "the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency and satisfaction in a specified context of use." Physicians remain largely dissatisfied with these systems, as well as overstretched by clinical demands, and it would be valuable to revisit the "specified goals" discussed in the above definition. Given the array of methods by which the practice of medicine can be optimally organized, success in fully supporting team-based medicine will require close collaboration between clinicians, payers, and the EHR vendor community.
1. Friedberg M, Chen P, Van BK, Aunon F, Pham C, Caloyeras J, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Santa Monica, CA: Rand Corporation; 2013. URL: http://www.rand.org/content/dam/rand/pubs/research_reports/RR400/RR439/RAND_RR439.pdf
2. American Medical Association. Improving Care: Priorities to Improve Electronic Health Record Usability. https://www.aace.com/files/ehr-priorities.pdf. Accessed February 7, 2017.
3.Bevan, N. (2005). International Standards for HCI, In Claude Ghaoui (Ed.) Encyclopedia of Human Computer Interaction. Idea Group Publishing. See also http://www.nigelbevan.com/papers/International_standards_HCI.pdf
About the Contributors
Paul Dexter, MD, Research Scientist, Center for Biomedical Informatics, Regenstrief Institute, Inc. and Associate Professor of Clinical Medicine, Indiana University School of Medicine. Dr. Dexter has been a research scientist at Regenstrief Institute for the last twenty years with a focus on clinical decision support and electronic health records.
Shaun Grannis, MD, MS, Interim Director and Research Scientist, Center for Biomedical Informatics, Regenstrief Institute, Inc. and Associate Professor of Family Medicine, Indiana University School of Medicine. Dr. Grannis collaborates closely with national and international public health stakeholders to advance technical infrastructure and data-sharing capabilities. He is a member of World Health Organization (WHO) Collaborating Center for the Design, Application, and Research of Medical Information Systems, where he provides consultancy on issues related to health information system identity management and implementing automated patient record matching strategies.