EHR & Good User Interface Design

I think I have mentioned before that I read the Kevin MD blog. Today, I read an interesting article. I did not agree with the writer’s ideas, but it made me think and that is a bloggers whole purpose. So while, my opinion is widely different from the author’s, I think the ideas are well worth consideration… then after reading my opinion, you can form your own.

The article was called The UserInterface for EHR Should be Uniform by Roheet Kakday.  In a nutshell the article discusses the challenges physicians face in learning to use multiple EHR systems such as their office EHR and the EHR for the hospital. The author believes that this is one of the problems slowing adoption. With that in mind, the author proposes that EHR user interfaces be uniform and even recommends a mandatory adoption of a single EHR vendor by region.

Again, I do not completely agree with this idea. Over time reading my blog the reader may begin to learn a little about my personality… but for the sake of this article, I will tell you flat out – I am very pro-capitalism – even when it comes to healthcare. In the article, Roheet Kakday says that capitalism leads to product diversification and stratification. I cannot deny that to be a fact. The difference between our opinion is the value of diversity and competition. I thoroughly believe that competition is the single most powerful driver of innovation. If healthcare providers, HIT vendors, etc. are constantly struggling to gain market share – they are bound to be striving toward better products and thereby better healthcare.

I believe that it is competition and the resulting innovation that makes the American Healthcare system the best in the world.  Think about it… people come to America from all over the world for healthcare. If you or a loved one were diagnosed with a terrible disease, perhaps a life threatening cancer, where would you go? I doubt Zimbabwe or New Guinea were the first places to came to mind.  Why is our healthcare better? Simply, we have the best resources – designed, built, and marketed because of competition.

Still there is a problem. If diversity is in fact preventing adoption, providers are therefore not sharing the benefits of capitalism (referring to superior technology created because of competition). Therefore the benefit is lost and capitalism is of no value in healthcare, right? NO, the value is still there but HIT vendors need to shape up and get it right. The problem is NOT related to diverse user interface, the problem is stupid user interface.

Before I go on, I want to back and explain user interface. I know that some of my readers are not overly technical and I hate when people speak jargon without considering clarity. So, allow me to explain in English. Everything computerized is made from a combination of hardware and software. Hardware is comprised of the tangible, mechanical parts. Software, however, is a little less tangible.

Software is an ‘instruction manual’ that tells the computer what to do. Software (as an instruction manual for the computer) is written in code that the computer can understand. Computer programmers are experts in code and ‘speak’ it as a another language. Most other people, however, cannot understand code. So, to make software so that non-programmers can use it – programmers and designers arrange pictures or simple (common language) words on top of the code.

These pictures are the buttons, links, and things you see and click on in any software program. For example, when you click on a button in a software program (like the save button or icon) – you are actually clicking on a picture that lays on top of an individual instruction that tells the computer what to do in response to your click. Since what you see on a software or website are all pictures on top of code these pictures, including all of the button, icons, etc. are called the graphical user interface or just user interface (sometimes also referred to as GUI or UI). 

Now that all readers are on the same page, we can go back to the point at hand – whether UI should be completely uniform. Personally, I do not think such a measure is fair to competition and I don’t think it is necessary. What I do think is necessary is that EHR vendors follow basic and generally accepted  in user interface design. Allow me to explain using an example.

Like most people, I do some shopping online from a variety of websites. Each website looks different or has a different user interface. When I started using these websites, no one came to my house to do a formal implementation or training. I just figured out how to use the websites myself. Also, like most people, I access several bank websites, for my mortgage, car, personal banking, and credit cards. Yet, again, no one taught me how to use these sites. So why is it that most of us can use so many websites without training, but EHR software are too hard to use?

The answer is simple. Shopping sites, banks, news sites all have common elements and a common arrangement. They are not uniform – but they share similarities that help us navigate easily. These commonalities are simply good user interface design. As an example of this, think about a shopping website – any one – what do you look for when you are ready to pay for your purchases? The shopping cart icon, right? Now think about how you search for something that is not immediately visible. Where is the search? Isn’t the search usually toward the top of the web page? Menus are often in a bar along the top of the page or to the right side.

With good UI design there is no inconvenient left to right scrolling and the most often used or most important things are visible toward the top of the page. Colors and shapes are also sometimes used as indicators or to draw the user’s eyes to a particular location. For example, red and bold attract the eye and hyperlinks are often blue until the user clicks on them and then they are purple to indicate that they were previously viewed. Further, think about a shopping web site… when was the last time you chose shipping options before selecting merchandise? Never. Why? Because websites are supposed to be designed to move in a rational order.

The problem with EHR is that vendors often ignore the virtues of good user interface design and user experience. We don’t need total uniformity. We don’t need to have our choices and competition limited. What we do need is for EHR vendors to adhere to good user interface design principles.  Here’s a clue to the EHR vendors… you are wasting time, effort, and profit on training and support. A little effort and time spent during the design process will benefit all parties far more and improve adoption. 

Has AllScripts Hit a Home Run in EMR Innovation?

I spoke too soon! In a recent post, I said that someone needed to design an app sytle EMR. Well, I should have known… AllScripts to the rescue! On April 5, 2012 AllScripts announced the release of the Wand, an iPad application that gives doctors mobile access to the most commonly used features of their EMR.

While I have not seen the Wand myself, the concept is GREAT and the company’s press release interviews an end-user who is quite pleased with the product calling it “elegant”. Most impressive, is how AllScripts designed the product and this design is why I am convinced that Wand is going to be a home run! Finally, an EMR company is taking user experience seriously. The Wand was designed, according to the press release, incorporating user-experience concepts and Human Performance Modeling.

For those not familiar, Human Performance Modeling is a performance modeling technique that incorporates both behavioral psychology (in other words, how people move and why) with best practices from concepts like Total Quality Management and Six Sigma. Human performance Modeling not only helps to make software usage more convenient but also (and most importantly) more efficient by eliminating performance gaps.

Like I said before, I have not had the pleasure to see the Wand, but if I get the chance you can be guaranteed I will revisit this topic in another post to tell you everything I learn about it. In the mean time, you can see the press release by following this link: http://www.healthcareitnews.com/news/allscripts-ipad-app-waves-wand-over-ehr-functionality

Or you can check out AllScrtipts website at http://www.allscripts.com/

EMR Innovation Should Be Spelled KISS: Keep it Simple, Stupid

In a recent post, I talked about an innovative EMR idea. I thought for this post I would back up and talk about innovation. Perhaps I can discuss my definition of innovation because the more I look around the less innovation I see.

The dictionary definition of innovation (according to the all-knowing Google)  is a create something new. I don’t like that definition. I think that is weak and limiting. Something can be new and completely useless or just plain badly designed. Would that be innovative? If it is, then I think innovative is a very sad word. To be innovative, something needs to be better, but not necessarily new.

For example, if we look at the iPod again, it was not a new concept, really. The iPod was a portable music player. That was not innovative. Walkmans were portable music players long before iPod existed. The innovation came in the fact that iPod was better than what came before it.

With that, I’d like to recommend a better definition of innovation. Innovation is a way of doing something that is better than anything that already exists. Innovation, therefore, can be an improvement on an existing concept and not necessarily something entirely new… it’s just better. An innovation should meet an unmet need, improve function, communication, and/or operations, etc.

In the healthcare IT world, there is very little innovation. For example, all EMRs do the same thing and generally that same thing is burdensome in many different ways. That is why healthcare information technology (IT) adoption is still relatively low – even with government incentives. The biggest problem in all of healthcare IT is that the current technology is not innovative (e.g. it is not an improvement). 

Now, I am not contradicting my previous posts here. There are some great ideas out there but I think the execution is still WAY off. I will share a story with you so you can see why I would say such a thing.

Some time ago, I did a site visit with a client where I shadowed my product’s end-users for a full day. The purpose of a site visit is so that I, as the product manager, can see what users need (because often they cannot really explain it clearly). During this visit, something very important happened and I had an epiphany. The nurse I was shadowing stopped her work to ask me how to perform a task on the system. The solution to her question was easy for me and the nurse was a little embarrassed so, she excused her question by saying “I am just no good with technical stuff”. What happened next struck  me.

Then, the nurses cell phone vibrated and she picked up her iPhone to answer. A few second in to her call she said let me check the bank and I will call you back and let you know. After hanging up, she used her iPhone to log on to her bank account. Then, she logged in to her email from her desktop computer, clicked on a hyperlink led to a product on Amazon.com. She proceeded to buy the product online, then return the call to say that she had bought the product. In a matter of 3 minutes, she used multiple technologies. Not tech savvy, hu???

As a good product manager, I had answer some very painful questions. For example, why is my software harder for her to understand than iPhone, email, bank, and Amazon.com? Then the really important question – the expensive question in the software world…. Why does my software requires weeks of end-user training and ongoing support when non-tech savvy people download and use apps, bank websites, and online retail with little to no training?

The answer is simple. Healthcare IT has forgotten about intuitive end-user design. I will admit, healthcare is complicated…but so is banking. If we want to improve adoption of IT in healthcare we need to simplify. That's right KISS, keep it simple, stupid. To do that, healthcare IT needs to include non-tech savvy users in the design and development process and in usability testing. I completely understand that such a proposal can be expensive to implement initially, but is it really more expensive weeks long implementation, ongoing support, and redesign after redesign in hopes of eventually getting it right?

Poor design in healthcare software is the problem preventing adoption. If we want to move healthcare in to the 21^st century in terms of technology, we really need to take a good long look at the technology that the self-proclaimed non-techie people are using. When a healthcare IT vendor finally comes up with a software that does not take months to implement  or years to really understand, technology adoption in healthcare will skyrocket. Remember, innovation is not necessarily something new.. it is something better. Simplifying something that is complicated is better… it is innovation.

(As an amusing side note… I keep referencing iPhone in posts but I am an actually Andriod user haha.)

Talking Goes Hi-Tech: NLP

Today, let’s talk about talking. You might be surprised that talking is going hi-tech, but it is! For years, medical care providers have been dictating medical records  and transcription companies have been typing those records. Innovations in speech recognition developed wonderful products like Dragon Naturally Speaking that changed how many providers document medical care. Now, speech recognition has gone to new levels with Natural Language Processing (NLP). NLP is not really new. It has been in development for well over 20 years but now it is catching on and changing healthcare as we know it.

So, what is NLP? Natural Language Processing is a form of artificial intelligence that, when used in healthcare, can identify important key components in a medical record and transform a narrative text (e.g. a story) into coded discrete data elements output in an XML format. With that said in such fancy terms, I will translate it to plain English with an example.

Let’s say that a doctor dictates the following statement: “John Doe is a 59 year old male with type 2 diabetes.”

NLP technology can take that statement and identify each important item in the statement individually, give it a header or a tag, and code it (if applicable), a little like this:  

patient name: john doe

age: 59

gender: male

diagnosis: type 2 diabetes

ICD-9 diagnosis code: 250.00

This is some impressive stuff! It opens up a world of automation related to regular-old speech in medical practices and hospitals. Innovative transcription companies, like StenTel, for example, are working with NLP technology from NLP developers such as MedLEE, CodeRyte, and IBM. Other companies like 3M, and  Nuance (the makers of Dragon Naturally Speaking) are also using NLP technology in a variety of ways from highly automated encoders to clinical documentation improvement to population health management.

For these technology companies and the providers of NLP technology, goal is two-fold. First, NLP can help improve provider reimbursement by helping coders to accurately identify patient conditions in otherwise messy and at times voluminous medical records. Secondly and perhaps more importantly, this technology opens the door for data mining and aggregation in ways that were never possible before. This is the heart and soul of the population health movement.  

With NLP technology, automated systems are able to warn us about impending outbreaks and so-called ‘clusters’ before they get too big. When we know where these condition ‘clusters’ are (cancer clusters, autism clusters, etc.) and when they are beginning, we are better equipped to find for the cause and implement the appropriate precautions to prevent further problems. Additionally, NLP offers the ability to analyze outcomes to see what treatments work and what treatments do not work for various conditions and diseases. With this kind of information, healthcare (diagnosis and treatment) will improve and become more affordable – all thanks to the handful of innovators developing and promoting NLP.

Innovation in EMR

So today, let’s talk about great technologies and awesome concepts. As a pre-writing disclaimer... I like these companies / technologies because they are great ideas but I am in no way, as of the date of this posting, affiliated with any of them.

Since the last few posts were about EMR, I will start with a great EMR concept called Hello Health. I have said before I have worked in EMR before, but I did not work for this company… although, I have admired Hello Health quite a bit for quite some time. 

Hello Health gives patients a better way to interact with their doctors. It has the elements of a traditional EMR (patient records, e-prescribing, etc) but also lets patients subscribe to features that improve patient-physician interaction. These features include the ability to securely email your doctor and “go to the doctor” using instant messaging and video conferencing.

The Hello Health business model is genius! Hello Health partners with the doctor’s practice to improve the doctor’s business thereby improving Hello Health’s business. This kind of upstream marketing is brilliant. Unfortunately, few companies understand the value of upstream marketing. The concept is simple. You sell a product to another business (a retailer, for example) who in turn sells the product to a consumer.  If you want to make your product sell, you help the the retailer sell to the consumer. The more the customer buys from the retailer, the more the retailer buys from you. Hello Health understands that and everyone benefits.

For physicians, Hello Health offers additional revenue by charging patients a subscription to have internet access to their doctor. Years ago, I worked in a physician’s practice and I can tell you from experience that many patients abuse the telephone and thereby the doctors time. Doctors do not get paid to return phone calls. Time on the phone results in lost revenue.  In the Hello Health model, patients pay a subscription fee to have secure internet access to their doctor.

For patients, Hello Health offers pure convenience! As a patient, I would gladly pay a subscription to eliminate the wasted time in a traditional waiting room for those little things. Obviously, some visits still must be done in person – but think about the little things like medication refills and follow up visits where the actual examination part is almost nonexistent. We have all experienced it… an hour long wait in an uncomfortable waiting room chair just to see the doctor for a 5 minute follow up. My time is too valuable for that, Hello Health offers the solution. With this technology, I would be able to ‘go to the doctor’ from my office or from home.

Hello Health is a great example of a great idea that satisfies a need and applies upstream marketing techniques. 

Successful EMR Implementations

I decided to skip the next obvious topic about choosing an EMR because, I think that topic has been exhausted everywhere. On the other hand, I can offer some practical advice on the best way to implement an EMR in a medical office.

The very first thing you must realize when you decide to move to an EMR is that your workflow will change. Don’t be deceived by any vendor who tells you otherwise. Still, that is not a recipe for disaster – it is one for improvement! You must be prepared to change the way you do things and you need to be ok with that. The change from a paper record to an EMR is a little like when we all began moving from typewriters to Microsoft Word. It was weird, right? It took a some adjustments, but soon you realized how much easier typing had become.

Once you are mentally prepared and understand that things must change (for the better) you are ready to go.  Having worked in healthcare for years both as a consultant and working with EMR, I have found that the best implementation practice is to have a staff cheerleader. The staff cheerleader needs to want the change and needs to drive the change. The staff cheerleader should also be what some people call the ‘super user’.

EMR vendors will either offer to do your implementation in person or virtually using web conferencing technology. Either way can be successful if you have a cheerleader/super user. That super user should be the first person trained directly by the EMR vendor and will not only drive the rest of the users to implement the EMR successfully  but also become the on-site ‘go to person’ for the rest of the staff. So, how do you find the right person to be the super user?

The super user must be a person who embraces change. This must be a person who is flexible and willing/capable of learning new things. A super user must be comfortable with technology. The best super users are those who are not afraid to play with a new software, even without or before formal training. Super users are by nature inquisitive and have a clear vision about how technology improves workflow.

Again, the super user is the cheerleader. This person has to be a leader who can encourage and motivate others to see the improvement ‘vision’. You can help the super user to be successful by giving that person clearly defined goals and authority. Without authority, the super user will not be able to drive change. This is not to indicate that the super user should become a dictator, but the super user needs to be able to set goals for the rest of the staff and offer positive reinforcement as needed.

Once you have identified the super user and the EMR vendor. Make sure that super user is an expert on using the software first – then he or she can train the rest of the staff. If you have a large practice, you may need multiple super users, even perhaps super users for specific segments (like billing, clinical, front desk, etc.) regardless having a super user(s) on staff is integral to a successful EMR implementation.

When the super user is ready, he/she should define incremental implementation goals. Don’t try to do everything at once. That will just overwhelm the staff (particularly those who are not comfortable with technology). Start slowly and add new things as staff becomes comfortable using the software. For example, your super user may choose to start by teaching the front desk to enter demographics and use the new software’s calendar. Once the staff is comfortable doing that, you can teach the staff how to verify eligibility electronically.  

Of course, this is just an example. In reality, some EMR software have these features intertwined so smoothly that you may choose to implement all those items simultaneously… but you get the idea… slow and steady wins the race! Your best bet is to ask your EMR vendor for help. The vendor knows the software and they have likely done hundreds of implementations just like yours. The vendor will be able to recommend how to break up the system in to incremental implementations.

Here, it is important for you to realize that this type of implementation will take longer than jumping in to it all at once. BUT, you will find that this is more successful. When you jump in too quickly, people get confused and make mistakes that WILL impact revenue and performance. If you take it slowly, implement in bite sized pieces over the course of 3-4 months, you will minimize (or even eliminate) any negative financial impact that could have resulted from the change in workflow.  

Introduction to EMR Part II

In the last post I mentioned the government incentives for doctors who meaningfully use an EMR. For many, the term meaningful use is a bit confusing. Really, though, it is quite easy. Meaningful use simply refers to using the best features of an EMR.

Last year, 2011, was the first year of meaningful use. In that first year the bar was set pretty low insofar as usage requirements. Basically, doctors had to use an 'approved' (certified) EMR the right way for just three consecutive months. The EMR that the doctor chose to use had to be certified according to ONC-ATCB requirements. The ONC-ATCB requirements simply ensured that the EMR had the necessary features to accommodate doctors needs and government requirements.

As of 2011, there were two companies testing and certifying EMR for ONC-ATCB certification. These are The Drummond Group and the Certification Commission for Health information Technology (CCHIT). These two companies have great websites that help a physician find a certified EMR product. If you are in the market for an EMR these websites are the best place to start.

Once you are on the site(s) you will see that there are two types of certification, complete and modular. Complete means that the EMR has proven that they have all of the components a physician needs to achieve meaningful use. A modular certification simply means that the software satisfies part of the requirements. If a doctor chooses a modular EMR s/he will need to use other technologies to fulfill some of the requirements for meaningful use. 

In other words, with a complete EMR – you have everything you need in one place. With a modular system, you will need to use multiple modular systems to meet meaningful use. 

While systems with modular certification may seem to be less useful – that is not necessarily true. Modular give you the ability to mix and match according to your preferences. So, in my opinion, either modular or complete are great depending on your preference for all-in-one or mix-and-match.

Now, let’s jump back to meaningful use. As I said before meaningful use really is easy but it may require a change in workflow…. Even so, it is a change for the better in most cases. Here is what meaningful use requires the physician to do in an electronic medical record:

• Prescribe electronically
• Turn on the EMR’s drug interaction warnings
• Report clinical quality measures to the Centers for Medicare and Medicaid Services (CMS)
• Enter patient demographics in the EMR (name, gender, date of birth, etc.)
• Keep an electronic record of patient’s diagnosis history
• Record patient allergies
• Record patient medications
• Record patient vital signs (height, weight, blood pressure, etc)
• Record whether a patient smokes
• Implement clinical decision support rules (automated reminders about how to handle certain medical situations)
• Provide medical records to patients within 3 days of their request
• Provide patients with a summary of their office visit within 3 days of the visit
• Test the EMR’s ability to electronically communicate with other medical providers
• Conduct a security and privacy risk assessment
• Turn on the EMR’s drug formulary system (checks if medications are covered by a patient’s insurance)
• Enter (or receive) lab results in the EMR
• Generate a list of patients by medical condition
• Send patient reminders about preventative care and wellness
• Give patient’s timely access to their medical information
• Provide patient educational materials
• Perform medication reconciliation when patient’s transition from other care providers (this means the provider must compare his/her list of medications to a list from the other provider)
• Test the EMR’s ability to submit immunization information to the appropriate state agencies
• Test the EMR’s ability to submit electronic disease information to a public health agency (health department, Centers for Disease Control , etc.)

See, there is nothing earth shattering in that list. These requirements will, however, get bigger as time goes by. But for now, meaningful use is simply a way to get doctors to get acquainted with using an EMR. Also, as you look over that list of requirements, it is pretty easy to see how useful these requirements are in patient care. 

To learn more about meaningful use and the EMR incentive programs, go to the Centers for Medicare and Medicaid website here: Overview of EHR Incentives

Introduction to EMR (EHR)

Considering my experience in EMR, I think a good place to start is talking EMR.

An EMR, for those who don’t know, is an electronic medical record. An electronic medical record virtually replaces all paper patient charts in a medical practice or hospital. Another term frequently used is an EHR or electronic health record. EMR and EHR are technically two different things but in common usage the terms have become synonymous. For the purpose of this blog, I will call it an EMR and assume that an EMR and EHR are the same.

We’ll start with a simple introduction to EMR.  In general electronic medical records all have the same basic features such as places to enter/store patient demographic profile, patient medical history, documentation for each patient visit, scheduler or calendar, and so on. An EMR program and all the patient data contained within can either be stored on a server (computer) in your office or it can be web-based. A web-based EMR holds the same type of information, but the data is stored on the software company’s servers and you access it over the internet.  

There are pros and cons for both. For example, if your EMR is stored onsite at your office, you need to take precautions against disasters that would cause you to lose information – like flood. Web-based EMRs generally have these precautions figured out. Web-based EMR companies use a facility called a data center to house their servers (and all of your information). EMR companies have multiple copies of all the information called back ups and some EMR companies have multiple data centers which means that if one data center has a problem – the other data center can take over and continue servicing the customers. On the other hand, web-based isn’t perfect either. If your internet goes down, you cannot access the patient records.

EMR became a huge topic of conversation back in 2005 when Hurricane Katrina destroyed parts of the south. Millions of medical records were lost in that disaster and many realized that EMR, particularly web-based, would have prevented the loss of that information. In 2009, President Obama signed the American Recovery and Reinvestment Act (ARRA 2009) in to law. Within ARRA, the HITECH act dedicated billions of dollars to health care IT such as EMR.

The manifestation of ARRA’s HITECH act is known as Meaningful Use. In a nutshell, doctors and hospitals can be paid incentive dollars by the government for implementing and using an EMR. If they refused to use an EMR, government insurances like Medicare will begin cutting their payments within 5 years. This is why so many people are talking EMR these days.

Still, there is more to it. It is not just the fear of natural disaster that prompted the EMR madness – it is patient wellbeing and ever-rising healthcare costs. EMR has features that help doctors and reduce mistakes. For example, most EMRs have features that help doctors write prescriptions and send those prescriptions to the patient’s preferred pharmacy. Writing a prescription on an EMR helps protect patients and keep costs down in two big ways.

First, doctor handwriting is messy (I think they learn how to scribble in 3^rd year med school). That messy writing can result in mistakes – either when the pharmacist fills the wrong medication or the patient takes it incorrectly…just because no one could read it. Secondly, EMR prescription writing software has built in warnings that will let the doctor know if s/he is prescribing something that the patient is allergic to or if s/he prescribes something that will have a negative interaction with the patient’s other medications. This is a huge help to doctors. 

Today, we have so many medications on the market , no doctor can remember everything. So EMR helps to prevent medical mistakes and thereby reduces the cost of healthcare. EMRs are good in other ways too. They keep all of the patient’s information in one place and it is always properly filed. This too helps to prevent medical mistakes from missed information such as family history of certain conditions that can be a warning sign for things to come for the patient.

So, that was a good start to what’s what with EMR. In the next post, we will get in to some more meaty stuff and I will talk about ways to successfully implement an EMR in a medical practice (it may sound like a no-brainer… but it’s more challenging that most realize).