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Defining EHR Usability Isn’t for the Timid

Note: This was also a guest publication on emrandehr.com

Sometimes it seems that EHRs and usability are like Earth and Mars. Their orbits get relatively close, but they’re never going to occupy the same place and time.

Of course, the two we’re occupied with aren’t cosmic equals. EHRs are specific systems, while usability is, at best, a concept with various definitions. In fact, the closer you get to a definition of usability the less focused it becomes. My late brother used to call things like that, “Far aways.” “The farther away you get the better they look.”

Indeed, most definitions of usability say it’s something that’s useful. Ugh. So, is there any way to bring some clarity to its definition, so it has greater precision?

Doing so, I think, requires not only defining what usability is, but also tackling when it’s not present what’s wrong.

Usability: A Different Definition Approach

Most definitions of usability I’ve seen push the issue off onto use or useful. That is, usability is defined as something that is useable. This isn’t far from using a word to define itself, which was a grammar school no no. It also fails to involve the user’s expectation. I would define it this way:

Usability is the ability of a system to supply a desired result with the minimum necessary information, conditions or steps.

This definition hinges on a user getting what they want expeditiously. Simply put, usability means no unneeded fuss or feathers. As I look at it, usability is to systems what parsimony is to logic. In logic, the simplest explanation that explains the occurrence is the best. Similarly, the most usable system is the one that requires the least effort to supply the correct response.

User Hostile Systems

If I left matters at this juncture, however, I wouldn’t have addressed a major related issue. When a system is user hostile, just where has it gone wrong. Each of us has experienced or heard these tales. You make a simple request and wind up in wilderness of documentation or your options are have everything but what you want.

These are negative examples of usability. It is, however, not enough to just stamp them as such and move on. It’s also important to say exactly where usability fails. To get a handle on these issues, I divide them into three classes:

Class One: Bug. Generally, a computer or software bug is anything that caused a wrong or unexpected response. I take a narrower view. To me, a bug represents a properly designed system that’s incorrectly implemented. That is, the program code fails to carry out the system designer’s intent. For example, you click Print and the system emails your Aunt Edna.

Class Two: Design Failure. In these, the code is OK, but the requirements failed. The classic refrain for these is, “ Yes, that‘s what I asked for, but it isn’t what I wanted.” Fixing these, unlike bugs, requires correcting the requirements and conforming the code.

Class Three: Missing Requirement. Sherlock Holmes in the Silver Blaze mystery had this to say about EHR usability:

“Is there any point to which you would wish to draw my attention?”
“To the curious incident of the dog in the night-time.”
“The dog did nothing in the night-time.”
“That was the curious incident,” remarked Sherlock Holmes.

Nothing is less usable than something that doesn’t exist. It’s not a matter of getting wrong. It’s a matter of not getting it at all.

What makes this a difficult category to apply is the issue of user need. What some users think is fundamental, others may regard as a frill or not necessary at all. Usability, therefore, hinges on neither design nor programming but on policy. However, if policy deems the function important, then its omission is far more serious than the other two categories.

An example. I use a large practice associated with a local medical school. It uses Jardogs’ Followmyhealth (FMH) web portal. It conveniently combines PHR, email and scheduling. I especially like being able to email my PCP. Recently, however, I ran into a class three problem.

FMH lists my PCP and any other of my providers. My PCP suggested I see a specialist for a problem. I went to FMH to find a list of specialists and phone numbers. I got nowhere. I could remove a provider, but not find a new one. I searched FMH’s knowledge base for provider and got 40 hits, but nothing on finding one. I then went through the FMH Patient Guide again without luck. Frustrated, I left the system and went to the practice’s public web site. It had the list. I found the department and number I wanted. Once I got set up, the new provider appeared in FMH.

Wondering if I had missed something, I called support with the problem. The support rep spent several minutes, came back, and confirmed that it could not be done, which surprised him. He agreed they should at least have a link in FMH to search for providers. Whether FMH adds it, of course, is a policy question.

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EHR Usability: Is There a Right Path?

Note: This was also a guest publication on emrandehr.com

Earlier this fall, the AMA sponsored a Rand Corporation study on physician’s professional satisfaction. Based on interviews with physicians in 30 practices, the study covers a variety of topics from workplace setting to quality of care, EHRs and health reform, etc. At the time, the report generated discussion about dissatisfaction in general with EHRs and MU in particular.

Usability, Part of MU?

Overlooked in the discussion was a new and important recommendation on usability. Here’s what it says:
Physicians look forward to future EHRs that will solve current problems of data entry, difficult user interfaces, and information overload. Specific steps to hasten these technological advances are beyond the scope of this report. However, as a general principle, our findings suggest including improved EHR usability as a precondition for federal EHR certification. (Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy, p.142) Emphasis added.
It would be overkill to say that this represents adopted AMA policy, however, it’s not overkill to say that the recommendation is part of a project that the AMA initiated and supports. As such, it is most significant that it recognizes the need to bring some coherence to EHR usability and that the MU system is the logical place to put it.

Changing the Vendor – User Relationship

One commentator who did notice the recommendation was EHR Intelligence’s Robert Green. In his review, Green took a different tack. While agreeing that usability needs improvement, he saw a different way to get change:

Usability remains an enigma in many clinic-EHR vendor relationships because it hasn’t been nearly as important in the recent years’ dialogue as “meaningful use.” But among the competing priorities, usability among physicians and their EHR vendor is a real opportunity to develop shared expectations for a new user experience.
As a patient, I would rather not see the delegation of the “usability” dialogue of EHR to those in the roles of meaningful use certification. Instead, physicians who have spent many years of their lives learning how to “take care of patients” could seize the moment to define their own expectations with their EHR vendor of choice within and beyond their practice. (How connected is EHR user satisfaction to vendor choice?) Emphasis added.

I think these two different paths put the question squarely. They agree that usability needs increased action. Users have gotten their message across with alacrity: all systems fail users in some aspect. Some fail catastrophically. Though some vendors take usability to heart, the industry’s response has been uneven and sporadic.

Where these two approaches differ is tactics. Rand looks at usability, and sees an analog to MU functions. It opts for adding usability to MU’s tests. Green sees it as part of the dialogue between user and vendor.

As a project manager and analyst, my heart is with Green. Indeed, helping users find a system that’s a best fit is why we started the Selector.

Marketplace Practicalities

Nevertheless, relying on a physician – vendor dialogue is, at best, limited and at worst unworkable. It won’t work for several reasons:

  • Nature of the Market. There’s not just one EHR market place where vendors contend for user dollars, there are several. The basic divide is between ambulatory and in patient types. In each of these there are many subdivisions depending on practice size and specialty. Though a vendor may place the same product name on its offerings in these areas, their structure, features and target groups differ greatly. What this means is that practices find themselves in small sellers’ markets and that they have little leverage for requesting mods.
  • Resources. Neither vendors nor practices have the resources needed to tailor each installation’s interface and workflow. Asking a vendor, under the best of circumstances, to change their product to suit a particular practice’s interface approach not only would be expensive, but also would create a support nightmare.
  • Cloud Computing. For vendors, putting their product in the cloud has the major advantage of supporting only one, live application. Supporting a variety of versions is something vendors want to avoid. Similarly, users don’t want to hear that a feature is available, but not to them.
  • More Chaos. Having each practice define usability could lead to no agreement on any basics leaving users even worse off. It’s bad enough now. For example as Ross Koppel points out, EHRs record blood pressure in dozens of different ways. Letting a thousand EHRs blossom, as it were, would make matters worse.

ONC as Facilitator Not Developer

If the vendor – buyer relationship won’t work, here’s a way the MU process could work. ONC would use an existing usability protocol and report on compliance.

Reluctance to put ONC in charge of usability standards is understandable. It’s no secret that the MU standards aren’t a hands down hit. All three MU stages have spawned much criticism. The criticism, however, is not that there are standards so much as individual ONC’s standards are too arcane, vague or difficult to meet. ONC doesn’t need to develop what already exists. The National Institutes of Standards and Technology usability protocols were openly developed, drawing from many sources. They are respected and are not seen as captured by any one faction. (See NISTIR 7804. And see EMRandEHR.com, June 14, 2012.)

As I’ve written elsewhere, NIST’s protocols aren’t perfect, but they give vendors and users a solid standard for measuring EHR usability. Using them, ONC could require that each vendor run a series of tests and compare the results to the NIST protocols. The tool to do this, TURF, already exists.

Rather than rate each product’s on a pass – fail basis, ONC would publish each product’s test results. Buyers could rate product against their needs. Vendors whose products tested poorly would have a strong incentive to change.

EHRs make sense in theory. They also need to work in practice, but don’t. The AMA –Rand study is a call for ONC to step up and takes a usability leadership role. Practice needs to match promise.

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