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How We Already Meet the AMA's 8 EHR Usability Priorities

by Mary Kate Foley, VP of User Experience

When the news broke last month that 25% of 62 ONC-certified EHRs had not been tested by physicians, — several had been certified with as few as two doctors — it brought home just how big the gap is between our human-centered design process at athenahealth, and what passes for acceptable ‘safety-enhanced design’ practice elsewhere. With our roots in a women’s health practice, we’ve always developed our services hand-in-hand with the people who use them, particularly physicians. It’s part of our process and our culture. And it is what led us to ranking #1 in the most recent KLAS EMR Usability Report.

With my user experience team of over 70 people, we’ve researched and tested our athenaClinicals EHR with thousands of physicians. It was shocking to realize there are EHRs out there getting certified without bringing a single doctor into this rigorous process. The discrepancy got me thinking about the eight EHR usability priorities the American Medical Association (AMA) published earlier this fall. Because we do so much research and testing, the AMA guidelines actually validate what we’ve long heard from doctors, nurses, staff and, of course, patients. Here is how our approach and processes match up with the recommendations of the AMA:

  1. Enhance physicians’ ability to provide high-quality patient care. We have a guiding principle that inspires our work: Uphold the sanctity of the moment of care between the patient and provider. To improve how our EHR supports that moment of care, we directly observe doctors, nurses and staff when they interact with patients; we design based on what we learn; we test with users at a variety of practices and enterprises; and, we make improvements before releasing an update. Then, because we are cloud-based service, we can measure providers’ use across our entire network, and pinpoint workflows that could be optimized further.   The AMA recommends that EHRs be “tailored to the end-user.” If they mean ensuring that the EHR reflects situational awareness at the point of care, and surfaces data appropriate to that situation and patient, we couldn’t agree more. The providers we talk to want nothing less.   But in our experience, no one can customize or tailor their way to better usability, no matter how much they wish they could. We find that, in many cases, the time spent customizing an EHR to accommodate personal preferences is wasted — the customizations don’t actually shorten documentation times, reduce EHR distractions during appointments, or improve patient outcomes. In my experience, it is far better to design the EHR to support situational rules about the data and features to surface for the best insight and care.
  2. Support team-based care. The athenahealth EHR is built on the premise of optimizing the efficiency of the dynamic care team, and already tracks and reports to each practice how well providers are delegating work to staff. Staff can take on the bulk of the data-entry burden for providers — and we can make it easier on everyone by making it obvious when required quality program data is missing.   Our research has shown that we can’t stop there — providers must be able to easily and efficiently consume any data their staff has collected on their behalf. Reducing the data entry keystrokes for physicians is meaningless if they’re saddled with a commensurate amount of scrolling just to sift through all that data. Our goal is to summarize data entered by the patient and other members of the care team so that the clinically relevant information is front-and-center for the physician (I elaborate on this in #5).
  3. Promote care coordination. We recognize there are several necessary components for effective care coordination. First, we seek to present the essential story of the patient, in one easy-to-read summary or briefing. Second, any traffic associated with the patient — orders and their results — needs to be communicated clearly, succinctly and reliably, so that no critical information is lost as the patient moves through various parts of the health system. Third, people who provide care must have the ability to easily, directly connect with other providers, without sacrificing security.
  4. Offer product modularity and configurability. As much as we invest in understanding our users’ unmet EHR needs, we recognize that we’ll fill those needs faster and better by integrating other components created by other smart, committed people. Maintaining walls between various vendors’ capabilities does neither the patient nor the provider any good.   With that in mind, we’ve opened our APIs so clients can snap in a module or capability from another company, which may better suit a particular client’s needs than what we’ve provided. Providers can explore the athenahealth Marketplace to determine offerings they’d like integrated into athenaNet — our cloud network — to better support their practice needs or workflow. Offerings range from digital check-in and medical image exchange to speech recognition.
  5. Reduce cognitive workload. Most EHRs are set up to collect as much data as possible — in some ways, just because they can. This means that each time a patient encounter is documented, the patient’s record grows — and the provider has a tougher time hunting for needles of clinically significant data in a haystack of a patient record. That haystack leads to cognitive overload.   To combat this, we work hard to summarize data in meaningful ways, and present it within clean layouts and visuals that are easier to understand. Instead of trying to make a tidier haystack, we’re working to pull that needle out and put it right where the doctor needs it. Our goal: make our EHR as easy to understand as the old note card physicians used to use — but a lot more reliable and safe.
  6. Promote data liquidity. Let’s face it, the data that’s hardest to use is the data that’s locked up in a closed system. For decades, EHRs have been designed to address care within one practice or one hospital system. But patients aren’t always that neat and predictable — they get care from a retail clinic, their PCP, an emergency department… And people who travel may seek care all across the country. Interoperability is essential to us because it’s essential for providers to have a full picture of patient care. It is why we promote open systems, proactively engage with any vendor that will open an exchange with us, and help lead movements like the CommonWell Health Alliance.
  7. Facilitate digital and mobile patient engagement. Analogous to bringing the needle to doctor is reaching out to patients wherever they are, using methods and devices that are convenient and familiar — and that means mobile. Our research shows that how you deliver the message — texting versus making a phone call, for instance — is important. And it’s just as important to leverage the patient’s desire for a strong relationship with their health care provider.   After the sheen of a new technology wears off for a patient, what really matters is who is engaging with them. Our user experience work on the athenaCommunicator patient portal is aimed at facilitating and enhancing that relationship between provider and patient. And I never get tired of hearing patient engagement success stories from our providers, like Dr. B. Christian Balldin of San Antonio Orthopaedic Group:   “Every single day I get messages from my patients. Having a mobile tool to communicate with a patient and get feedback is instrumental in providing good care for that patient. I wish 100% of my patients would do stuff online. I really do think it improves patient care.”
  8. Expedite user input into product design and post-implementation feedback. As I’ve mentioned, we have a robust user experience program that any of our clients — and many of our prospective clients — can participate in. It relies on validating research methodologies to collect input and feedback on an ongoing basis, before and during design phases, and after a feature is released. But we don’t stop there.   We’ve recently taken our user experience program to the next level through our partnership with the Seaport Community Health Center in Belfast, ME. We collaborated with practice management, physicians, nurses, therapists and pharmacists at Seaport, to design and build a health center that would support the delivery of excellent care, while enabling our ongoing research. At Seaport, we watch health care in action and see how we can improve our services to support them. In turn, Seaport is an early beta user for our new and improved capabilities. (We’ll have more details on this exciting venture in 2015.)
To make health care work the way it should, that’s how you’ve got to do it: get honest input from physicians and the people who support them in providing care. Every week. Every feature. And not just when a certifying body is asking you to document how you tested your EHR. And I’m not saying we’re perfect — we have usability issues like the best of them, but we’re continuously improving. It’s a longer road than I’d like, but through our continued work with our physicians we hope that together we can re-imagine what an EHR should be.

The AMA has it right. And if this list inspires health IT vendors to improve their processes, that’s fantastic. But these items are really fundamental to good EHR usability and, perhaps, should already have been addressed in the first place.

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