Designing EHRs Starts in the Field

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by Bob Schumacher and Gavin Lew

This is the first in a series of posts discussing electronic health record (EHR) systems.  Why a series?  There’s a lot to talk about, including many myths and misunderstandings about EHRs.   These are a few of our thoughts; do you agree?  Disagree? Have other ideas?  Let us know what you think.

If electronic health record systems (EHR) are as helpful to medical practice as it seems they would be, why have such a small percentage of physicians adopted them?  And why has no single company emerged as a frontrunner in the EHR field?  There’s probably not one easy answer.  The more we thought about it, we came to believe that the problem might lie with the technology-centered view that has dominated the field.  

Most EHR applications are database-oriented.  It’s a linear process – symptom, diagnosis, treatment, and then billing.  The problem is that the practice of medicine isn’t clear-cut.  It’s messy.  Patient/physician encounters are filled with nuances and complexities. It’s not easy to document everything that occurs during an office visit by clicking boxes.  Even paper files themselves – age, thickness, notes -- convey clues that may, even subconsciously, direct a doctor’s understanding.  Subjective impressions can be difficult to capture in an electronic format.  But if EHRs can’t capture this information, they will only be helpful in a limited way.  They’ll handle billing and insurance, but won’t really help the doctors become better at what they do.  Distilling all the information from a patient visit into a database may, in fact, be taking valuable diagnostic tools away from physicians.

So the question becomes, how can we design a better mousetrap?  Thorough research is essential.  Before building an electronic health record system, we need to observe healthcare professionals as they work.  Understand the kinds of questions they ask and the reasons they ask them.  Watch for subjective cues that may inform a doctor’s decision-making process.  Review existing records and have medical professionals explain just how they use them.  Learn about gaps in knowledge.   This information isn’t easy to get at, but it’s essential if we want to avoid turning physicians into mere documenters.  While taking advantage of the benefits of the EHR, we need to preserve the richness and artistry of what it means to be a diagnostician.  The shortcoming in most current systems isn’t with the technology or the database, the missing piece is a real understanding of the physician’s experience and the clinical workflow.  Research is the key to gaining that insight.  

In future posts we will be highlighting how implementing a calculated research strategy (1) involving ethnographic and in situ research to learn about workflow, (2) understanding clinical needs and user needs to create an exceptional user experience, and (3) applying a robust user testing program that would result in a better, more adoptable EHR - one that would not just store data, but would add value to a doctor’s time and expertise.  It would extend the capabilities of medical professionals, help them work smarter, and give them the information they need to make the best decisions they can on behalf of their patients.   We feel that in the end, the system that emerges as a leader in the EHR field will be the one who thoroughly researches the full experience of care delivery, and is able to develop that experience into a usable interface. 

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