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Better usability, framing of EHRs as clinical tool could boost acceptance

Dr. Shannon Dean
At the recent WTN Media Digital Health Conference in Madison, Dr. Shannon M. Dean, medical director of inpatient informatics for UW Health and American Family Children's Hospital noted an interesting paradox: Her 18-month-old daughter can use an iPad, but many highly educated physicians continue to shun computers or at least avoid making them a central part of clinical practice.

The fact is, according to members of a panel on the slow evolution of the culture of health IT, that many electronic health records (EHR) systems are just not user-friendly, and that has prevented EHRs from having more impact on healthcare costs and quality of care.

"I don't think anyone would be mystified if I said usability, usability, usability," offered Dr. Seth Foldy, a former director of public health for the State of Wisconsin and, before that, the City of Milwaukee.

Computers in medicine, Foldy said, should perform three basic tasks: help clinicians make decisions, help them execute decisions and improve communication, but sometimes they are too complicated. "We have to start becoming extremely simple about how many hoops people have to jump through," said Foldy, who now is a Milwaukee-based consultant in preventive health systems and informatics after a two-year stint with the federal Centers for Disease Control and Prevention (CDC) in Atlanta.

To Dean, usability is just one of many issues in the slow march toward EHRs reaching their full potential. "I do think there is widespread reluctance to embrace these systems, but for a variety of reasons," said Dean, a pediatric hospitalist.
"A lot of things that are provided in training are not necessarily intuitive on a screen," Dean suggested. She said that lack of standardization of workflows across a health system on a single platform is another barrier.

Foldy said that the Medicare and Medicaid EHR incentive program known as Meaningful Use does help nudge healthcare toward standardization, particularly from his perspective in public health. "Meaningful Use is a painful process that pushes us somewhat down that road," he said.

Jocelyn G. DeWitt, CIO of UW Health, contended that IT standardization is exceedingly difficult in healthcare because there is no single "industry" for a vendor to build to, since healthcare organizations are all so different. "Healthcare is not a single industry. It never has been," said DeWitt.

DeWitt did say, however, that there was "some amount of bait and switch with this in that there were huge expectations created" by vendors and health system executives alike. Organizational leaders failed to communicate the need for clinicians to be partners in all aspects of EHR design and implementation. "I think the vendors underestimated this as well," DeWitt said.

Dean largely agreed. "There needs to be less emphasis up front on the bells and whistles of health IT and more emphasis on the clinical benefits," she said. Dean suggested that framing the EHR and related efforts like health information exchange as a clinical operations project rather than an IT project might result in more clinician buy-in.

"The EHR is not treated like other tools for clinical care," Dean noted. This, in her opinion, creates reluctance among clinical staff to commit to some of the education needed to use an EHR.

DeWitt said there was an "arbitrary distinction" between IT and clinical care, one that can easily be avoided by treating the EHR like any other clinical tool. "You don't have a stethoscope budget, you have a clinical care budget," she said.

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