Electronic Health Records (EHRs) are often cited as a contributor to physician burnout but may also be carrying the water for other problems within the US health care system they didn't create, according to findings from a recent perspective essay in the Journal of the American Medical Informatics Association. The essay was written by an AMA research team led by Michael A. Tutty, PhD, the Association's group vice president of professional satisfaction and practice sustainability.
While EHR vendors take a brunt of the blame for poor EHR usability, several influences within the US health care system are also contributors to a less than ideal EHR user experience. Are there actually opportunities to improve EHR usability?
Multiple requirements underly the composition of EHRs and vendors don't always consistently follow them. According to the essay, there is a "lack of vendor adherence to ONC certification requirements and usability testing standards in their certified EHR products." The authors add "vendors have misperceptions about and variability with their approach to user-centered design practices." That creates problems for users.
Another huge concern? Some vendors don't involve clinicians in usability testing of their products, which the authors cite from a JAMA study:
- 63% of vendors used less than 15 people in usability testing of their products.
- 51% did not include demographic data of their usability participants.
- 17% did not have any physicians testing their products.
- 12% lacked enough detail to know if physicians participated in testing.
"Many EHR products were designed with billing, payer requirements, and meaningful use criteria in mind, rather than clinician use," say the authors.
Health IT vendors, too, influence the interoperability between EHRs. "Across vendors, there is variation in data formats (technical interoperability), lack of shared meaning (semantic interoperability), and unusable delivery to physicians, further limiting interoperability." In addition, vendors influence the success of an organization's implementation of their EHR product by their recommendations for training, timelines, and technical configurations.
Roots of frustration outside of the EHR system
It's easy to heap blame on EHR vendors for the clerical burdens associated with their products. But that would take others off the hook for EHR contributions to physician professional dissatisfaction and burnout.
In the JAMIA paper, Tutty and colleagues note that "the primary goal of the EHR should be to support patient care." But a host of other parties have piled on with "non-value-added tasks" that can take a majority of some physician's day, including one to two hours of "pajama time" in the evening completing EHR-related work.
Payers, lawmakers and regulatory bodies all have had a hand in creating a situation that leaves too many physicians feeling like documentation drones instead of doctors. Issues created by government regulation, payment and quality reporting, and lack of widespread interoperability all create less than an ideal EHR user experience.
Seven forces behind the issue
The AMA researchers note these seven influences that have created the challenges in EHR-use.
- Government regulations that increase data-entry requirements beyond what is needed for patient care.
- Shifting targets for payment and quality measures that create barriers to the efficient use of EHRs.
- The sluggish pace of interoperability improvements.
- Health care organization governance practices.
- Decisions on implementation, training and customization.
- Practice design and resource allocation that don't accommodate workflow and clinical space needs.
- Vendor design and development, including the lack of clinicians in usability testing.
Distilling a solution for improved usability
The AMA is committed to making technology an asset in the delivery of health care, not a burden. So, in addition to noting how different parties contribute to the problem, the AMA authors also write how they each can be part of the solution. Because — as the authors note — the burden cannot be solved by a single stakeholder.
Keys to progress:
- Easier documentation requirements can be made by payers and regulators.
- Improved task time can be done by tracking EHR click, motion and time-screen data by quality officers and practice administrators.
- Physician engagement in EHR implementation processes by organizational leadership.
- Pre- and post-implementation testing with rigorous real-world scenarios.
- Health IT vendors increased transparency around product costs, functionality, performance, and support in advances in AI with a focus on user-centered design that improves interoperability and use.
"There are multiple opportunities for regulators, policymakers, EHR developers, payers, health system leadership and users each to make changes to collectively improve the use and efficacy of EHRs," concludes the authors.