Darwinian Health IT: Only well-designed EHRs will survive

Remember the Ford Pinto and the AMC Pacer, aka the Pregnant Pinto? Both serve as reminders of an era in which the American auto industry lost its way and assumed drivers would buy whatever they put on the lot. Foreign competition, primarily from Japan, filled the void created by American apathy for quality and design, and the industry has never been the same.

Admittedly, the comparison of cars and EHRs is less than apt, but health IT also assumes healthcare will buy what we’re selling because the feds are paying them to. And, like the Pinto, what we’re selling inspires something less than awe. In short, we are failing our clinical users.

Why? Because we’re cramming for the exam, not trying to actually learn anything.

Myopic efforts to meet certification and compliance requirements have added functionality and effort tangential to the care of the patient. Clinicians feel like they are working for the system instead of it working for them. The best EHRs are focused on helping physicians take care of patients, with Meaningful Use and ICD-10 derivative of patient care and documentation.

I recently had dinner with a medical school colleague who gave me insight into what it’s like to practice in the new healthcare era. A urologist in a very busy Massachusetts private practice, he is privileged to use what most consider “the best EHR.”

Arriving from his office for a 7 PM dinner, he looked exhausted, explaining that he changed EHRs last year and it’s killing him. His day starts at 7 AM and he’s in surgery till noon. Often double or triple booked, he sees 24 patients in the afternoon, scribbling notes on paper throughout as he has no time for the EHR. After dinner he spends 1.5 to 2 hours going over patient charts, dictating and entering charges. What used to take 1 hour now requires much more with the need to enter Meaningful Use data and ICD coding into the EHR.  He says he is “on a treadmill,” that it should be called “Meaningless Use,” and he can’t imagine what it will be like “when ICD-10 hits.”

My friend’s experience is representative, not anecdotal. A recent survey by the American College of Physicians and American EHR Partners provides insight into perceptions of Meaningful Use among clinicians.  According to the survey, between 2010 and 2012, general user satisfaction fell 12 percent and very dissatisfied users increased by 10 percent.  Michael S. Barr, MD, MBA, FACP, who leads ACP's Medical Practice, Professionalism & Quality division, drew this conclusion:

Dissatisfaction is increasing regardless of practice type or EHR system. These findings highlight the need for the Meaningful Use program and EHR manufacturers to focus on improving EHR features and usability to help reduce inefficient work flows, improve error rates and patient care, and for practices to recognize the importance of ongoing training at all stages of EHR adoption.

Additional survey results show dramatic and pervasive dissatisfaction:

  • Clinicians who would not recommend their EHR to a colleague increased from 24 percent in 2010 to 39 percent in 2012.
  • 34 percent of users were “very dissatisfied” with the ability of their EHR to decrease workload -- an increase from 19 percent in 2010.
  • 32 percent of responders had not returned to normal productivity since EHR implementation compared with 20 percent in 2010.
  • Dissatisfaction with ease of use increased from 23 percent in 2010 to 37 percent in 2012.
  • Satisfaction with ease of use dropped from 61 to 48 percent.

Clearly, the usability of EHRs has gotten worse with the implementation of Meaningful Use. Many have been coded to certification requirements, not designed to make achieving Meaningful Use a byproduct of improved workflow automation. Where basic EHR usage is not already established, bolted on functionality forces clinicians to take additional steps that further disrupt workflow.

The tag line is that usability and good design matter. They always have. An elegant, flexible system can accommodate new requirements. Adding more stuff to an incoherent system just creates an unmanageable mess.

Consider clinician satisfaction with the usability of leading enterprise EHRs according to the ACP survey.  When asked which system were most usable, results show that clinicians ranked VistA best overall with a score of 4.06, ahead of Greenway (3.83), EpicCare (3.51), McKesson (3.10), Meditech (3.08), Allscripts (3.06) and Cerner (2.93). This is no accident. Built long before Meaningful Use, VistA was designed with physician and patient needs foremost. Indeed, VistA was one of the EHRs the Office of the National Coordinator evaluated to come up with Meaningful Use criteria.

Physicians need and desire systems that help them do their work, and only those systems that are designed with clinical efficiency—not mandated behavior—in mind will accomplish this task. Again, Meaningful Use measures and their health IT representation should be derivative, not additional, which requires iterative real-world design. The systems that score the highest have been pounded on by physicians for years. Their development teams obviously listened to end users.

According to Modern Healthcare, natural selection may already be taking place in the EHR environment as Meaningful Use 2014 and Stage 2 introduce more exacting requirements. The magazine’s review of federal records shows a massive drop in the number of health IT systems being tested for Stage 1 2014 and Stage 2 certification.  While around 1,000 EHR technologies were certified for 2011 Stage 1 requirements, as of last week only 79 systems were certified for 2014 standards. Almost all companies are scrambling. Some will get certified in time. Many more won’t.

“This is just the beginning of the shakeout … there is an asset bubble in electronic health records and health IT,” said Dr. David Brailer, founder and CEO of Health Evolution Partners and former head of the Office of the National Coordinator for Health Information Technology.

“The data suggests that it is likely we'll see a sizable reduction in the number of EHR vendors listed for 2014 edition certification,” predicted Steven Posnack, director of federal policy, and Dustin Charles, a public health analyst, on the ONC’s September 13 blog post

Now to the question: “ICD when?” Mandated for October 2014, ICD-10 is expected to be one of the most complex and expensive changes healthcare has faced in decades. Look, for example, at this simple numerical comparison prepared by the American Medical Association.











Pressure Ulcer Ankle




Clinicians are now going to have to provide more specifics on their ICD coding. With the pressure ulcer example below, you can see the increased level of specificity that will be required for reimbursement.

Example for pressure ulcer with ICD 10 changes in bold:



  • Site
    • Ankle
    • Back
      • Lower
        • Coccyx
        • Sacrum
      • Upper
        • Shoulder blades
    • Buttock
    • Elbow
    • Head
    • Heel
    • Hip
    • Other
    • Unspecified
  • Stage
    • Stage I
    • Stage II
    • Stage III
    • Stage IV
    • Unstageable
    • Unspecified
  • Site
    • Ankle
    • Back
      • Lower
      • Upper
        • Shoulder blade
      • Unspecified part
    • Buttock
    • Contiguous sites of back, buttock, hip
    • Elbow
    • Head
      • Face
    • Heel
    • Hip
      • Sacral Region
        • Coccyx, tailbone
    • Other
    • Unspecified
  • Stage
    • Stage 1
    • Stage 2
    • Stage 3
    • Stage 4
    • Unstageable
    • Unspecified
  • Laterality of limbs and trunk
    • Right
    • Left
    • Unspecified






Specificity is very helpful in understanding patient condition and care.  But how does the system support requirements and usage? Does it just layer the work on the clinician to point and click away? There is no way ICD-10 can create extra time in the day. Physicians, already showing a dramatic despondence with regard to career satisfaction, may start heading for the exits in larger numbers. Emergency physician shortage, anyone?

The ACP survey is ongoing.  The 2014 surveys will show which systems dealt effectively with clinician questions and which did not. Even before survey results are published, clinicians may provide answers themselves by replacing their work-creating EHRs with systems that actually ease the burden.

In my estimation, we have all the predictive evidence we need. Meaningful Use 2014 is a tipping point and ICD-10 will only tip the whole project further. This is EHR survival of the fittest. Did you choose a survivor or, better yet, a thriver?  If not, the real usability and accessible Meaningful Use data available from systems designed with clinician and patient in mind can help you find a better way.


Hello Dr. Billings, your assessments are spot on! Your findings are consistent with what many of us who have both worked with EMR’s and are now working hard to make them usable for physician’s has experienced.

The point that resonated the most – “Physicians need and desire systems that help them do their work, and only those systems that are designed with clinical efficiency—not mandated behavior—in mind will accomplish this task.”

With this in mind, there are tools that support clinical workflow through the use of Speech Recognition, and not just the traditional speech to text dictation that you may be familiar with, but EMR navigation as well.

Chad Hiner RN, MS
Director, Healthecare Industry Solutions
nVoq, Inc.

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