EHR usage update
We are now three years into the Centers for Medicaid and Medicare’s Meaningful Use EHR adoption incentive program. According to CMS’s website, as of March of this year, $14.8 billion in payments have been made to the over 470,000 providers and hospitals participating in the program. Those are some big numbers! But what about the people who are using the systems? Can we tell whether or not any of this is making a difference in quality of care? What about health care provider workflow or job satisfaction?
Earlier this year, the Annals of Internal Medicine published a systematic review, carried out by the Rand corporation and funded by the Office of the National Coordinator (the main federal body overseeing Health IT efforts) which examined the effectiveness of several Health IT system functionalities, including those required to achieve Meaningful Use, for improving the delivery of health care. In the review, they evaluated 236 articles published between 2010 and 2013. 36% of the studies selected addressed clinical decision support (CDS), 21% computerized provider order entry (CPOE) and 20% looked at more than one functionality that’s required for Meaningful Use. The authors looked at quality, safety and effeniency outcomes reported in the articles. Overall, the measure of efficiency seemed to be the most mixed bag of positive, negative and neutral outcomes, illustrating that in clinics Health IT systems both increase efficiency in the some cases and cause a time burden in others. They noted that though there is an increasing amount of literature looking at these sorts of issues, findings remain inconclusive, owing to methodological limitations, especially failing to take into account details around organizational context and system deployment. In most studies though, both CDS and CPOE show primarily positive effects, noting specifically that CPOE reduces medication errors.
While these results are touted by HealthIT.gov, at the same time we’re hearing a lot of dissatisfaction amongst EHR users. This can be seen both through more formalized surveys and anecdotally via blog articles and blog commenters (scroll to bottom for comments). What can be driving this seeming disconnect between the clinical care improvements suggested by research findings and the groaning and anger we see on a provider level? Perhaps the answer is in user experience and usability. Let’s consider how this could play out through a more universal computer experience than an EHR: a calendaring system. Imagine a person works for a company that has a required company-wide (maybe even in-house designed) online calendaring system. The system possesses none of the intuitive functionalities we come to be expect through Google calendar and it doesn’t integrate with the company’s email so each appointment must be entered painstakingly by hand. This isn’t an issue related to a learning curve – each time entering an appointment is as difficult as the last. These difficulties may lead to feelings of frustration and employees to complain and protest. At the same time though, because they are using a calendaring system and not trying to keep appointments and meetings in their head (or on paper), the employees are alerted by their computer when a meeting is about to occur and thus are less likely to be late. So – the system is working, but it might not feel like it to the end user. When the user experience is poor, dissatisfaction will be high. This is probably why we are hearing talk that 2014 is the year of the EHR platform switch, with one in six providers unhappy enough to plan on changing EHRs.
There are, of course, other factors that can be causing the dissatisfaction seen amongst EHR users, such as cost, workflow issues, poorly managed implementations, and feelings that systems are focused on billing rather than patient care, to name a few prominent ones. Looking forward though we will hopefully see improvements in usability promoted to a higher level of importance. Calls from groups like AMIA to improve Health IT usability will spur usability assessments and research into better system design, like this recent eye tracking study that examined how doctors look at electronic charts. Findings from studies like these will lead to improved interface design and from there, greater user satisfaction and potentially patient safety outcomes.