Fix EHR Usability



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Commentary — August 2016 

Tex Med. 2016;112(8):11.

By John Pettigrove, MD

I used to be a computer geek. I still use complex software, but I haven't written any programs in years. Hassles regarding meaningful use and quality measures take up a lot of a physician's time and have little, if any, relevance to the physician's practice of medicine. 

With all that in mind, I do not know of any serious physician who objects to real quality improvement. 

Most quality measures, designed around financial considerations like cost, have become a game. Most physicians do not play the game well, and those who do play it well are often gaming the system. 

Financial considerations alone have created "quality" metrics that hospitals and third-party managers strive to follow. Often, hospital managers' careers depend on their metric performance. The agreed-upon strategy among managers is to control physician behavior. Noncomplying physicians are judged not so much for misbehavior but for compliance with those metrics. This is not a conspiracy. It is the intent of people not familiar with health care who are trying to manage cost while mistrusting all providers, including physicians.

Meaningful use also has become a game. Hospital managers play the game most skillfully. A major complaint among physicians, as you may suspect, is usability. Software developers have known this for a long time. Usability is not a concern for most of those paying for software development. Early in the process, when I was part of a team trying to upgrade the electronic health record (EHR) system for a major hospital in our community, I interviewed multiple software development companies. 

Their software engineers told me frankly that usability was not a priority. In their words, "Usability stifles innovation." I think they meant that data acquisition was their focus. While that view has not dramatically changed, those developers may be starting to come around. 

Ask yourself how Apple can secure an iPhone that took the FBI months to break and how Adobe can create complex usable software like Photoshop, yet we cannot create a secure health care network with data transfer. We have the communications technology, and we have the software developers, but we do not have the will to modernize our systems. Few hospital EHR platforms — even in hospitals in the same system using the same program — can communicate with one another. I suggest that the major software providers have little incentive to make their products usable. 

Few physicians have been involved in software development. The grandfather of the EHR was called MUMPS (a programming language that originated at Massachusetts General Hospital in the late 1960s), which was the creation of physicians and developers. EHRs have not been appreciatively changed or modified since then.

What I thought would be a bright future for computer databases in clinical practice back in 1974 remains largely unrealized. The EHR has evolved into little more than an elaborate billing document and unfortunately remains a clinical impediment. This is a sad indictment for a technology that promised to be a godsend for patients, physicians, and nurses. 

The solution is not to throw out the EHR. The real problem is that lack of usability stifles innovation among health care providers. Fix that problem, and we have a new beginning. Big data should not feel as though "Big Brother is watching you." It should be an asset and a problem solver. 

How did we get here? It has been all about the money.

John Pettigrove, MD, is a retired internist in Nueces County and a former member of the Texas Medicine Editorial Board. 

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