Federal government incentives worth about $30 billion have persuaded the majority of physicians and hospitals to adopt electronic health record (EHR) systems over the past few years. However, most physicians do not find EHRs easy to use.
Physicians often have difficulty entering structured data in EHRs, especially during patient encounters. The records are hard to read because they're full of irrelevant boilerplates generated by the software and lack individualized information about the patient.
Alerts frequently fire for inconsequential reasons, leading to alert fatigue. EHRs from different vendors are not interoperable with each other, making it impossible to exchange information without expensive interfaces or the use of secure messaging systems.
EHRs are designed to support billing more than patient care, experts say. They add to, rather than reduce, the workload of doctors. And they don't follow the principles of user-centered design (UCD), which puts the needs of the user at the forefront of the design and development of products and systems.
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The American Medical Association in 2014 issued an八点框架for improving EHR usability. According to this framework, EHRs should:
- enhance physicians' ability to provide high-quality patient care
- support team-based care
- promote care coordination
- 提供产品的模块化和可配置
- reduce cognitive workload
- 促进流动数据
- facilitate digital and mobile patient engagement
- expedite user input into product design and post-implementation feedback.
然而，它不会出现EHR厂商更加重视UCD。卫生国家协调员办公室IT需要开发人员进行可用性测试的认证过程，使他们的电子健康档案符合政府的电子病历激励计划的一部分。然而，一个recent study发现，41家EHR厂商是公开发布的报告，超过半数使用的行业标准UCD过程少。只有九个开发商测试他们的产品有至少15名人参加谁了临床背景，如医生。
Regulatory barriers
政府规定是即兴表演的一个关键障碍ing the usability of EHRs, says Peter Basch, MD, medical director for ambulatory EHR and health IT policy at MedStar Health, a Washington, D.C., healthcare system. For example, he notes, EHRs were easier to use before developers were required to design them in a way that enables them to collect quality data for the government's EHR incentive program. (Physician practices and hospitals must gather this data on health care processes for a certain percentage of Medicare or Medicaid patients to show "meaningful use" of EHRs so they can qualify for incentives and/or avoid financial penalties.)
Another downside of the meaningful use program, says Basch, who advises the American College of Physicians on health IT, is that vendors have had to focus on rewriting their software to meet the changing EHR certification criteria. As a result, they have had little bandwidth left over to meet the needs of their customers by building more user-centered products.
The other big regulatory obstacle is the billing guidelines of the Centers for Medicare and Medicaid Services (CMS), which are followed by most private insurers. The guidelines for "evaluation & management" (E&M) billing codes specify that physicians must document that they have performed a certain number of services to claim a particular coding level for the length and complexity of patient visits.
因为医生可以收费的金额visits depend on these codes, EHR developers designed their products to help physicians justify their coding levels in case of an audit. This was a big selling point, especially in the early years of EHRs.
However, this approach has had some unintended consequences. First, it forces physicians to follow EHR templates of drop-down click boxes that do not necessarily reflect how they conduct encounters with patients. Second, it makes them spend too much time entering data. And third, the resulting computer-generated notes are often unreadable.
Part of the standard templates that doctors are supposed to follow, for example, is the "review of systems," which covers all of the body's physical systems. In an EHR, the review of systems may include hundreds of check boxes. Most of these are inapplicable if, for instance, a physician is setting a broken bone, notes Mark Anderson, a health IT consultant based in Montgomery, Texas.
Some EHR vendors tell physicians to simply use a macro that checks off all of the boxes as "normal" findings, he says, and then change the ones that are not normal. But when the EHR converts the structured data into text, this approach generates five pages of descriptions of the normal findings, which are irrelevant to the case.
豹驰说，E＆M编码规则必须进行改革之前，电子病历可以成为一个真正可用的。但是，这是不可能的，只要发生的费用仍然是服务报销医师的主要方法。在有意义的使用方案，同时，也没有固定的终点;事实上，该计划的第三阶段定于2017年开始。
文档和笔记
医生对EHR最大的抱怨是，它减缓下来，特别是在图纸设计阶段。“比起手写或口述，电子病历需要更长的医生九次输入数据，”安德森说。“当然，你必须在EHR比在纸上记录的详细信息，但它需要更多的时间。”
最后，他说，自然语言处理（NLP）会变得足够好，使其能够从听写文本中提取最相关的概念，并将其放置在结构领域。考虑到药物，诊断和实验室结果已经编码，他指出，NLP引擎有文本的只有一小部分转化为结构化数据。
Meanwhile, however, many physicians stumble along, working longer hours to get their visit notes into the EHR. Doctors who sluffed off the initial training are in much worse shape than those who paid attention and tried hard to learn the system, Basch points out. Mature users like himself can document fairly rapidly by using a combination of point and click, typing, and dictation with speech recognition. But physicians who are fairly new to EHRs—a majority of users at this point—may have a lot of trouble keeping up with the flow of information.
Many doctors have developed workarounds. Either they dictate the majority of their notes, which produces a mass of unstructured text, or they copy and paste parts of previous notes into current ones. The latter method not only increases the risk of errors, but also may create the appearance of fraud. And it increases the problem of locating important information later on in the copious, repetitious text while trying to treat patients.
Alerts are out of control
除了文档，电子健康档案一般包括应该提高质量和安全警示。这些措施包括弹出当病人需要建议的预防性或长期护理警报。其中一些提醒的是无关的，或者是因为病人不适合的参数或者是因为在其他地方进行护理。
Other alerts go off to prevent adverse drug interactions with other medications, allergies, or foods. Many of these are inapplicable to particular patients, and after a while, doctors may stop paying attention to them or turn them off. Three quarters of EHRs don't allow the customization of these alerts, according to Anderson.
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Most EHRs were designed for primary care, so they don't work well for other kinds of specialists, he notes. Some good specialty EHRs exist, but not in all specialties, and those EHRs may not be interfaced with an organization's enterprise system. Epic and Cerner, which make the leading EHRs that cover both hospital and ambulatory care, provide decent templates for inpatient specialists, Anderson says.
Toward a more usable EHR
为了节省时间，豹驰想有一个可以重复使用信息的电子病历。这将使他，例如，在系统中填充文件已经使用的数据，比如事先授权形式。
他也会喜欢“智能”电子病历，在背景的地方的信息。“当我看肝功能实验室结果，我不只是想看看结果之前，我想看看其他的事情，如果他们的提升，”他说。“因为现在我做的手工给我一个MED列表，显示我吃药，患者是那些可能影响肝功能，或者告诉我影像学检查。”
Anderson hasn't seen any EHRs that can reuse data or apply it intelligently, as Basch describes it. This is a next-generation concept for vendors, he says. In fact, he hasn't even seen an EHR with alerts that correlate medications with lab results.
What many physicians want in an EHR, Basch says, is something as simple and intuitive to use as an iPhone, but he thinks it's a mistake to "dumb down" these systems.
"That would cause much of what I'm expecting from my EHR to disappear. In fact, I want it to help me with the complexity of patient care. I want it to present me with a rich context as simply as possible in a way that I can see it and not ignore it."
This story, "Why Electronic Health Records aren't more usable" was originally published byCIO .