How to Select an Electronic Health Record System that Healthcare Professionals can Use

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User Centric identifies a five-step process for specifying and measuring the usability of EHR systems. These steps are intended to help guide selection of an EHR that meets the criteria for high levels of effectiveness, efficiency, and subjective satisfaction among healthcare providers. User Centric believes that EHR systems selected in this manner are more likely to be adopted, meet the needs of their users, and reduce the chance of usability-related abandonment.
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  Version 1.1 © Copyright 2009 -– User Centric, Inc. Page 1 of 14All Rights Reserved How to Select an Electronic HealthRecord System that HealthcareProfessionals can Use   Robert M. Schumacher, Ph.D.Jayson M. Webb, Ph.D.Korey R. Johnson, M.S.User Centric, Inc.February 2009 User Centric, Inc.2 Trans Am Plaza Dr. Suite 100Oakbrook Terrace, IL 60181+1.630.320.3900© Copyright 2009 – User Centric, Inc.  Selecting a Usable EHR Schumacher, Webb, & Johnson2/3/2009   Version 1.1 © Copyright 2009 -– User Centric, Inc. Page 2 of 14All Rights Reserved Introduction Electronic Health Records (EHRs) are currently used by 12% of physicians and 11% of hospitalsnationwide (Hagen, 2008). Industry and government have promoted EHRs as a means of controllingcosts and improving patient care. In fact, the Obama administration has set an agenda that includesmaking “the immediate investments necessary to ensure that within five years, all of America’s medicalrecords are computerized” (Obama, 2009). While the universal nationwide adoption of electronic medicalrecords is highly unlikely within five years, governmental, technical and industry impetus for adoption ishigh, which will continue to drive EHRs into the hands of medical providers.The promise of EHRs being able to transform medical practice – saving lives, money, and time – hasbeen around for some time, but the fulfillment of this promise in real-world applications has remainedelusive due to many factors. Among the most frequently cited are cost of implementation, privacy andsecurity. While overcoming these factors is necessary to the successful implementation of any EHRsystem, they are hardly sufficient. To understand why the adoption rate of EHRs has been low, Gans etal. (2005) surveyed experts at nearly 3000 group practices nationwide. As shown in Table 1, Gans et al.identified 15 barriers to EHR adoption. Table 1. Barriers to EHR adoption. Copied from Gans et al (2005)  Selecting a Usable EHR Schumacher, Webb, & Johnson2/3/2009   Version 1.1 © Copyright 2009 -– User Centric, Inc. Page 3 of 14All Rights Reserved When inspecting this table, some interesting observations emerge. Certainly, well-known factors likesecurity and cost are cited as key factors, but another theme – usability – floats near the top. Usability israrely mentioned by name as a barrier to EHR adoption   by respondents at these group practices; yet, twoof the top five barriers to implementation are related to the usability of EHRs (items 3 and 4). And whileimplementation costs are important barriers to practitioners, some of the other popularly cited reasons for lack of adoption – security, privacy, and systems integration – are outranked by usability and productivityconcerns.Usability issues are also a factor in why EHR implementations fail. In a survey conducted by Linder et al.,(Linder, Schnipper, Tsurikova, Melnikas, Volk, & Middleton, 2006), primary care physicians were asked tolist reasons they did not use the EHRs available to them. Thirty-five percent of those physicians listedspecific EHR usability issues, the most common of which were: problems with screen navigation, noaccess to secondary functions, and concerns that data will be lost.Anecdotal support for usability and EHR failure comes from Cedars-Sinai Medical Center in Los Angeles.They developed a $34 million Computerized Physician Order Entry system, but only included the input of a few physicians before launching it hospital-wide in late 2002 without thorough training (Connolly, 2005).Physicians who were used to scribbling a few notes by hand were now required to go through nearly adozen screens and respond to numerous alerts for even common orders. Such usability issues with the“clunky and slow” interface caused more than 400 doctors to demand its removal within three months of its launch (Ornstein, 2003). Poor usability can also endanger patient health. One example of a usabilityfailure was a display that did not clearly indicate stop orders for treatment, leading to reported cases of unnecessary drug doses. The Associated Press (2009) reported that “patients at VA health centers weregiven incorrect doses of drugs, had needed treatments delayed and may have been exposed to other medical errors due to the glitches that showed faulty displays of their electronic health records.” Thisprompted the chairman of the House Veterans Affairs Committee, Rep. Bob Filner (D-California) to statethat … confidence must be inherent in any electronic medical records system. Where does the process break down? If we accept that usability issues are a material factor in the low rates of EHR adoption and success, wemust ask the question – why is usability an issue? To find the answer, we looked at system requirementsduring procurement and whether usability was being sufficiently emphasized.During the procurement process, purchasers (e.g., group practices) have the opportunity to specify thefeatures, functions, and capabilities important to the institution and its users, usually in the form of aRequest for Proposal (RFP) document. RFPs can be written by the institution itself, but smaller andspecialized practices often inherit RFP content from government, trade or professional associations. For instance, a small dermatology practice might look to the American Academy of Dermatology for guidance  Selecting a Usable EHR Schumacher, Webb, & Johnson2/3/2009   Version 1.1 © Copyright 2009 -– User Centric, Inc. Page 4 of 14All Rights Reserved on what is important in the procurement of an EHR. There are, therefore, three main sources for RFPcontent: the purchaser itself, the government, and professional associations.In view of this, we reviewed a sample of publically available RFPs for EHRs. In November 2008, wedownloaded and inspected the selection criteria of nearly 50 publicly available RFPs (See Appendix 1 atend of paper). Of these, more than two thirds did not include any criteria for usability; this is reflected bythe lack of inclusion of terms like “usability” or “user experience” or “ease of use” or “user friendly.” Theymade no attempt to specify the role of usability in the selection of the EHR. Of the remaining RFPs, lessthan 10 had guidance that was superficial at best (e.g., Demonstrations are evaluated on intuitivenessand usability ). Only a few sources had any systematic guidance for including usability as a keyevaluation and selection criterion.Even the Certification Committee for Health Information Technology (CCHIT), the EHR industry’scertification body, specifically states in its Certification Handbook (CCHIT, 2008) that “our criteria do notasses product usability.”Clearly, there is a dissociation between the importance of usability and its lack of inclusion in theprocurement process. On one hand, we have usability being a main barrier to entry and a significantreason for lack of acceptance, and on the other, we have seen that usability is largely ignored during theprocurement process. Usability in the EHR Selection Process As usability issues are key determinants as to whether an EHR will be successfully adopted or implemented, usability should be a priority within an RFP and when selecting an EHR system. Whyusability has not been emphasized may be due to a number of factors.First, RFP writers may simply not be aware of the important role of usability, despite existing data thatshow that usability is important. Second, RFP writers may not be familiar with how to write usabilitycriteria in tangible terms or how to enforce their criteria when evaluating EHRs. In our examination of theavailable RFPs, user experience requirements and guidelines were vague and poorly defined when theywere mentioned at all. This was true of RFPs and RFP templates published by hospitals, as well as withsuggested EHR selection criteria published by national associations. Third, it may be that the scienceand methods of usability—those derived from experimental psychology—are perceived as too soft,unreliable or lacking ecological validity. Last, there could be the perception that including usabilitycriteria will add unnecessary cost to the procurement process.
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