Towards a New EHR Metaphor

News flash: docs hate Excel!  In a recent study, which included researchers from Yale, the Mayo Clinic, Stanford, and the AMA, physicians rated it only at 57% on a usability rating, far below Google search (93%), Amazon (82%), or even Word (76%). 

But, of course, Excel wasn't their real problem; the study was aimed at electronic health records (EHRs), which physicians rated even lower: 45%, which the study authors graded an "F."  If we want EHRs get better, though, we may need to start with a new metaphor for them.

Credit: Yale News

Lead author Edward Melnick, MD, explained the usability issue: "A Google search is easy.  There’s not a lot of learning or memorization; it’s not very error-prone. Excel, on the other hand, is a super-powerful platform, but you really have to study how to use it. EHRs mimic that."

The study took great pains to include physicians from all specialty disciplines and across a range of EHR platforms, and used the System Usability Scale (SUS) to allow comparisons with other technologies.  Although the overall usability rating was dismal, it did show considerable variation (+/- 22%), such as by specialty (anesthesiologists highest, general surgeons the lowest) or practice location (VA highest, academic medical centers lowest).   

The authors did caution: "survey respondents may conflate their EHR usability with the burdens of documentation due to regulatory, clerical, or administrative requirements or local implementation that manifest in the EHR."  I suspect this is a very valid concern. 

Credit: Medical Economics 2019 EHR Scorecard

The study, of course, is not the first to point out poor physician perceptions of EHRs. For example, Medical Economics' 2019 EHR Scorecard found a 2.8 (out of 5) satisfaction score for physicians' current EHR.  Only 9% rated them a 5, whereas 19% gave a 1. 

Sixty percent would not choose their existing system if they had a choice, which may help account for the alarming fact that three-fourths have personally used 3 or more EHRs.  Seventeen percent have used over 10!

No wonder usability is an issue. 

Almost half of the Medical Economics respondents felt that EHRs have harmed the quality of care they provide, and 60% believed it has harmed patient engagement.  Even though critics claim EHRs focus more on billing than patient care, twice as many physicians said their EHR had a negative impact on their practice's finances. 

I've always wondered why healthcare professionals/institutions didn't seek competitive advantage by computerizing medical records, in the way they did, say, billing, claim submission, and other administrative matters.  Instead, they waited for HITECH to help finance the conversion, and we got stuck with largely legacy systems that have led to the above state of affairs. 

We had a once-in-a-generation opportunity to define what a "patient record" was.  We blew it.  We've poured billions of dollars into EHRs, and -- despite their woeful satisfaction -- few in the healthcare system are going to be eager to scrap all that spending,  But we must. 

We've been using the wrong metaphor. 

Let me explain.  Fast Company featured an excerpt from Cliff Kuang's new book, User Friendly: How the Hidden Rules of Design Are Changing the Way We Live, Work, and Play that might help explain.  Mr. Kuang says, "In the user-friendly world, interfaces make empires," and those interfaces rely on metaphors. 

He cites the example of smartphone and the app economy, which has flourished but which, he believes, is reaching its limit.  He goes on to say:

...the metaphor that begot the app economy was the wrong one. Underlying the structure of all the apps we use is the internet, and its infinite web of connections. But we consume apps through the metaphor of the store, through the assumption of stand-alone goods that we use one at a time, rather than in a web of references.

Resolving them will require a new metaphor for how smartphones work, and when someone finds it, our digital lives will evolve. Imagine if instead of apps, our smartphones were built around the relationships we care about...Who knows how much easier, how much more satisfying, our digital lives might be if the governing metaphor for smartphones were one of human connection, rather than programs.

I think Mr. Kuang's advice can be applied to EHRs.  Who knows, indeed, how much better they'd be if their governing metaphor was one of human connection. 

The metaphor for EHRs was, of course, paper medical records.  Transactional, siloed, for use by professionals, and whose focus on data was mostly as an afterthought.  Those might have sufficed in a paternalistic healthcare environment, populated largely by solo practitioners, most of whom were primary care physicians, but that is not the world we live in today, and that cannot be the metaphor we use. 

Healthcare is a team effort.  Many people have multiple health issues, and are seen by multiple healthcare professionals in several settings.  We know that most of what impacts a person's health happens outside healthcare settings, and that most of their support comes from friends and family.  More people want to be involved in their care, and should be. 

Credit: Microsoft

Maybe what we should be using as the metaphor for EHRs is Slack or Microsoft Teams, with maybe a little Snapchat added in.  Slack and Microsoft Teams recognize that business relies on collaboration, and requires communication and efficient sharing of information.  So does healthcare. 

We need to bring the patient into the metaphor.  We need to build around their stories, their lives.  We need data from their daily lives.  We need to help them coordinate with all the touchpoints healthcare forces them to have.

We need to make EHRs about what is happening in the patient's life, not about what a healthcare professional is doing to them.  We need to turn it into a visual, interactive experience, not one of check boxes and dry measurements.  We need to incorporate visual technologies like photos, videos, VR, AR, and holograms. 

And we need to stop perpetuating EHR monoliths and start developing healthcare's Linux. 

Both Slack and Microsoft Team see healthcare as a growth market, and I'd urge them, and other entrepreneurs: don't think small.  Think about developing a new metaphor for EHRs.  Goodness knows we need one.