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How to Improve EHR Usability: First, Listen to the Clinician
By Matthew Douglass

The modern Hippocratic Oath encourages physicians to "remember that there is art to medicine as well as science" and when treating a patient, they "do not treat a fever chart, a cancerous growth, but a sick human being." Also included in this pledge is the crucial recognition that physicians can't do it all by themselves: "I will not be ashamed to say 'I know not,' nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery."

According to a paper on evidence-based medicine, a general practitioner would need to read 19 articles every day just to keep up with the flurry of modern clinical advancements. Given that independent physicians may see up to 40 patients daily, it stands to reason that they are hard pressed to read 19 articles every month, let alone in a single day. To efficiently and intelligently treat sick human beings and prevent disease in the 21st century, physicians need smarter technology tools, integrated seamlessly into their practice. Most importantly, these technology tools need to untether practitioners so they can focus their energies on helping to improve their patients' lives.

While technology has proliferated in the modern medical practice, there is a lingering feeling that the tools themselves have wrested focus away from the patient. Most physicians spend far too much time working in their EHRs and on other nonclinical administrative tasks. In a recent study, researchers found that internal medicine residents spend, on average, three hours with computers for every one hour spent with patients. It is easy to see why EHRs are singled out as a primary source of provider burnout and usability of EHRs rates poorly across most software vendors.

If physicians would rather treat sick human beings than spend excessive time entering data into their EHRs, why haven't digital health technology vendors delivered tools that fully unlock this potential? John Halamka, MD, MS, CIO, one of the most prominent health care technology experts in the United States, reporting from 2017 HIMSS, points to the primary reason: "[T]echnology developers devote the majority of their development resources to fulfilling government requirements instead of innovating to meet market and clinician demands. The certification program ... made sense eight years ago when IT adoption in health care lagged considerably behind all other sectors, but today the certification program impedes a functioning market and must be reformed."

In a short period of time, largely because of the ARRA, droves of physicians across the United States have adopted EHR technology for their practices that meets a minimum feature threshold intended to conform to prescribed regulatory standards. An unintended consequence of this rapid digitization is that software originally intended to help physicians run their practices has actually made it more complicated. While the EHR industry has succeeded at what it was asked to do by regulators, digital health tools have not yet achieved their long-term goals of improving patient outcomes and empowering smarter medicine.

EHR vendors have offered clinicians digital tools that are really just physical-world analogs. Encounter notes in an EHR are a replacement for paper chart notes, problem lists mimic physical lists of patients' diagnoses, and lab results delivered electronically look exactly like lab results delivered via snail mail. In each case, clinician usability and satisfaction suffer because vendor focus has been on digitization, not fundamental improvement. Fortunately, we are still in the early days of rolling out health technology for the modern practice, so hope is not lost for better software that assists physicians in providing consistently better patient care.

Vendors that are accustomed to asking, "What is required to be a federally certified EHR?" must shift their product development mindset toward the clinician. Ultimately, physicians do not want to spend a majority of their time working with the computer. A clinician-first software vendor actively asks questions such as, "If you could automate just one rote task from every single patient visit, what would it be?" and "What do you waste the most time doing every day that you wish was just taken care of in the background?" After all, alleviating repetitive tasks and human pain points should be core goals of all technology.

What might a clinician-first software development mentality look like? At a bare minimum, it means meeting users where they work, by visiting practices for in-person user research. Systematically observing and asking detailed questions of a physician and her support staff for an entire day can provide immense insight into the unique challenges of a modern independent medical practice.

Since it's impossible to meet with every clinician in person, a common technique in modern software design and development is to develop and utilize general personas based on those in-person meetings. Personas were popularized last century by design guru Alan Cooper, and we use them to great effect at my company, Practice Fusion. The overarching goal of this technique is to challenge every participant in the development process to take themselves out of the situation, since he or she is not going to be the real user of the product. Cooper describes the intent of personas succinctly: "Until the user is precisely defined, the programmer can always imagine that he is the user."

Imagine how dramatically improved clinician satisfaction and usability would be if every EHR vendor truly listened to their customers and delivered exactly what practices of any size need in order to do their jobs more efficiently. Now that the United States has largely passed the "base functionality" hurdle of EHR implementations, we can set our sights on a new, more clinician-centric technology future.

Digital health companies that are serious about partnering with physicians to achieve the lofty goals set forth in the Hippocratic Oath must fundamentally reorient themselves toward a more clinician-centric approach to software development. When medical students begin studying for their careers, they first pledge to "do no harm." EHR vendors interested in thriving should adopt a health care software maxim of their own: "First, listen to the clinician."

— Matthew Douglass is cofounder and senior vice president of customer experience at Practice Fusion. His Twitter is @MotoWasHere.