Rethinking EHR Usability

Many doctors using EHRs are working longer days than ever while wondering what happened to the promised time savings. As an early adopter and EHR promoter, I would say that promise was never made. Most analyses showed that EHR use, where doctors were voluntary adopters and well trained, would at best be time neutral, but had potential for cost savings and revenue enhancements.

Just because our days are longer and we are now mostly using EHRs, EHRs are not necessarily the cause and certainly not the only cause. EHR design and functionality should improve but I am concerned that just making EHRs more usable will do little to improve our days.

Do you remember the so-called documentation challenges of a decade ago? The idea was that for an EHR to prove feasible, a doctor had to be able to create a visit note in the same time or less than scribbling non-standard abbreviations on paper. But often not part of this challenge was how long it took to handwrite a good, legible note, informed by prior results and treatments and meaningful to the next provider of care and to the patient.

Second, regulatory requirements have added tasks and time for some, particularly when prior to using an EHR, those tasks were not done or at least not consistently done. I find, for example, that managing the med list for my older patients who see multiple docs is often the most time-consuming, adding 1-5 minutes per visit. I could conclude that this is a failure of my EHR. However, while my EHR could be more usable, the EHR component to the extra time spent on a careful med review is relatively small.

Third, for some of us, care has changed since adopting an EHR. This may be most apparent in outpatient primary care practice. About a decade ago, several authors did time studies of primary care docs and what their days would look like if they incorporated into their usual care all of the recommended preventive and chronic care activities from various organizations. They concluded that it would add somewhere between 5-12 hours per day to the then average 9-10 hour day—an impossibility. 

However, with even mediocre EHRs, it is now possible to be aware of and even address many of these unmet care opportunities and not by adding hours but minutes. So again, while my EHR needs to be better, this extra time I am spending with patients is made possible by the EHR. While my day is longer, the patient is saved an additional visit; and for many of us, our patients are not where they were a decade ago when it was determined that Americans were on average, receiving appropriate preventive and chronic care about half of the time. 

Yes, we need more usable EHRs. However, as usability requirements differ by specialty and scope of practice, and Meaningful Use certification requirements are the same for everyone, unless MU changes I believe it is more likely to continue to foster mediocre systems than the better systems we all need.

Even if MU changes, I don’t think payers and other stakeholders will make the changes at their end such that a highly functioning EHR will be anything but a more pleasing experience. We will still have to go through the wasteful activities of duplicative documentation for forms and prior authorizations just to get things done.

Yes, let’s make EHRs more usable but how about making healthcare operations more usable at the same time (or maybe even first)?=

Peter Basch, MD, is medical director of ambulatory EHR and health IT policy at MedStar Health based in Columbia, Md.