AMA Calls for More User-Friendly EHRs

Ken Terry

September 18, 2014

Citing a RAND Corporation study showing that the majority of physicians are dissatisfied with their electronic health record (EHR) systems, the American Medical Association (AMA) has called for a major overhaul of these systems to make them more user-friendly and better able to support clinical care.

"Physician experiences documented by the AMA and RAND demonstrate that most electronic health record systems fail to support efficient and effective clinical work," AMA President-Elect Steven J. Stack, MD, said in a news release. "This has resulted in physicians feeling increasingly demoralized by technology that interferes with their ability to provide first-rate medical care to their patients."

Largely because of the increased burden of documentation in EHRs, the AMA said, most physicians are less productive than they were before they implemented the systems. However, the association did not place all the blame on EHR vendors.

"The AMA recognizes that not all EHR usability issues are directly related to software design itself," the statement said. "Some issues are a result of institutional policies, regulations, and sub-optimal implementation and training. The AMA will continue to move aggressively on these fronts, including empowering physicians to work with vendors and other[s] to develop and implement more usable products."

8-Point Framework

To this end, the AMA released an 8-point framework it said would help improve EHRs. The framework's "usability priorities" include:

  • enhance physicians' ability to provide high-quality patient care,

  • support team-based care,

  • promote care coordination,

  • offer product modularity and configurability,

  • reduce cognitive workload,

  • promote data liquidity,

  • facilitate digital and mobile patient engagement, and

  • expedite user input into product design and postimplementation feedback.

The Healthcare Information and Management Systems Society Electronic Health Records Association (EHRA), which represents the larger vendors, said in a statement that it has been cooperating with the AMA and the American College of Physicians for several months to address EHR usability issues. The association praised the AMA's framework and said vendors also want to lower barriers to usability so that physicians can use their products to improve the safety and quality of care.

In an interview with Medscape Medical News, Sarah Corley, MD, vice chair of the EHRA and chief medical officer of NextGen, said, "Provider and vendor groups understand what needs to change both in our products and in the environment that physicians are practicing in today."

The AMA recognizes that EHR design is only part of the problem, she said. "Implementation decisions, regulatory requirements, and concerns about malpractice all play a role in adding to the burden of documentation using EHRs."

Physicians in many practices are expected to document everything in the EHR instead of delegating some of that work to other staff members, she said. "In most cases, physicians should not be the ones documenting. We should have everyone working to the top of their license."

One reason why this happens infrequently is that providers are concerned about regulatory compliance, she noted. "We need to have payers, regulators, auditors, and compliance people come to a consensus on what documentation physicians must enter themselves into the software, and where it's appropriate to have others entering information."

Other nondesign factors also reduce usability, including unwise implementation decisions and the physical layouts of offices and hospitals, she said. In many care settings, it may be difficult to use large computer screens or other means of helping physicians maintain eye contact with patients while documenting.

In addition, she pointed out, physicians do not always get the amount of training they should because they are too busy. "We've seen studies showing that when physicians have more training, they're happier with their EHRs. We want to encourage that and bring to the physicians' attention the importance of training."

She did not deny that EHR designs may be less than optimal but attributed some of this to government-imposed timelines that have been too short to allow time for adequate software development. "When you have shorter development cycles, you don't always have the time to be as thoughtful as you might in incorporating the functionality into an intuitive workflow."

"Transition to Value"

Michelle Holmes, a principal at ECG Management Consultants in Seattle, Washington, agreed that government requirements, including those for the EHR meaningful use incentive program and the International Classification of Diseases, 10th Revision, transition, "have made it hard for vendors to focus time, attention, or [research and development] dollars on usability."

However, she noted, other industries have devised more sophisticated methods than health information technology companies to understand the effect of new technologies on end users. So far, there has been little market demand for the vendors to do that, but that will change, she said, as the industry moves from fee-for-service to value-based reimbursement.

"As we transition to value, there will be a lot more opportunity and flexibility" for new EHR designs, she said.

Holmes praised the AMA framework for change and the RAND study that underlies it. "This was a well-articulated response to what they found in that study," she said. Likewise, the 8 goals were well thought out, she said. The key to success, in her view, will be getting feedback from frontline physicians who are not tech savvy.

Both Holmes and Corley predicted it would take some time to achieve the AMA's goals for EHRs. "Many of these things have regulatory implications in terms of team-based care, for example, and who can document what," Corley said. "A lot of these things have external constraints on them, so I don't think it can happen rapidly. But they've certainly identified what is important."

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