Wednesday, December 03, 2014

A new "Better EHR" book and an observation re: health IT regulation, health IT amateurs, and user centered design (UCD) - "responding to user feature requests or complaints?"

A new book has appeared on improving usability of electronic health records.  The result of government-sponsored work, the book is available free for download.  It was announced via an AMIA (American Medical Informatics Association, listserv, among others:

From: Jiajie Zhang []
Sent: Tuesday, December 02, 2014 6:00 PM
Subject: [Implementation] - New Book on EHR Usability - "Better EHR: Usability, Workflow, and Cognitive Support in Electronic Health Records"

Dear Colleagues,

We are pleased to announce the availability of a free new book from the ONC supported SHARPC project: "Better EHR: Usability, Workflow, and Cognitive Support in Electronic Health Records". The electronic versions (both pdf and iBook) are freely available to the public at the following link:

First, this book appears to be a very good resource at understanding issues related to EHR usability.  I particularly like the discussion of cognitive issues.

However, this book also holds messages about the state of the industry and the issue of regulation vs. no regulation, and impairment of innovation:

I think it axiomatic that user-centered design (UCD) is a key area for innovation, especially in life-critical software like clinical IT.  (I would opine that UCD is actually critical to safety and efficacy of these sophisticated information systems in a sociotechnically complex setting.)

I think it indisputable that the health IT industry has been largely unregulated for most of its existence, in the manner of other healthcare sectors such as pharma and traditional medical devices.

Yet, even in the absence of regulation, the book authors found this, per Section 5 - EHR Vendor Usability Practices:

a)  A research team of human factors, clinician/human factors, and clinician/informatics experts visited eleven EHR vendors and conducted semi-structured interviews about their UCD processes. "Process" was defined as any series of actions that iteratively incorporated user feedback throughout the design and development of an EHR system. Some vendors developed their own UCD processes while others followed published processes, such as ISO or NIST guidelines.

Vendor recruitment. Eleven vendors based on market position and type of knowledge that might be gained were recruited for a representative sample (Table 1). Vendors received no compensation and were ensured anonymity.

Vendors generally fell into one of three UCD implementation categories:

Well-developed UCD: These vendors had a refined UCD process, including infrastructure and the expertise to study user requirements, an iterative design process, formative and summative testing. Importantly, these vendors developed efficient means of integrating design within the rigorous software development schedules common to the industry, such as maintaining a a network of test participants and remote testing capabilities. Vendors typically employed an extensive usability staff.

Basic UCD: These vendors understood the importance of UCD and were working toward developing and refining UCD processes to meet their needs. These vendors typically employed few usability experts and faced resource constraints making it difficult to develop a rigorous UCD process.

Misconceptions of UCD: These vendors did not have a UCD process in place and generally misunderstood the concept, in many cases believing that responding to user feature requests or complaints constituted UCD. These vendors generally did not have human factors/usability experts on staff. Leadership often held little appreciation for usability.

About a third of our vendor sample fell equally into each category.

In other words, a third of health IT sellers lacked the resources to do an adequate job of UCD and testing; and a third did not even understand the concept.

Let me reiterate:

In an unregulated life-critical industry, a third of these sampled sellers thought 'responding to user feature requests or complaints constituted UCD'.  And another third neglected UCD due to a 'lack of resources'.

I find that nothing short of remarkable.

I opine that this is only possible in healthcare in an unregulated healthcare sector.

Regulation, for example, that enforced good design practices and good manufacturing practices (GMP's) could, it follows, actually improve clinical IT innovation considering the observations found by these authors, through ensuring those without the resources either found them or removed themselves from the marketplace, and by making sure those sellers that did not understand such a fundamental concept either became experts it UCD, or also left the marketplace.

I can only wonder in what other fundamental(s) other sellers are lacking, hampering innovation, that could be improved through regulation.

As a final point, arguments that regulation hampers innovation seems to assume a fundamental level of competency and good practices to start with among those to be freed from regulation. In this case, that turns our to be an incorrect assumption. 

As a radio amateur, I often use the term "health IT amateurs" to describe persons and organizations who should not be in leadership roles in health IT, just as I, as a radio amateur, should not be (and would not want to be) in a leadership role in a mission-critical telecommunications project.

I think that, inadvertently, the writers of this book section gave real meaning to my term "health IT amateurs."  User centered design is not a post-accident or post-mortem activity.

-- SS

12/4/2014 Addendum:

I should add that in the terminology of IT, "we don't have enough resources" - a line I've heard numerous times in my CMIO and other IT-related leadership roles - often meant: we don't want to do extra work, to reduce our profits (or miss our budget targets), or hire someone who actually knows what they're doing because we don't really think that the expertise/tasks in question are really that important.

In other cases, the expertise is present. but when those experts opine an EHR product will kill people if released, they find the expert 'redundant', e.g.,

Put in more colloquial terms, this is a slovenly industry that has always made me uncomfortable, perhaps in part due to my experience having been a medical safety manager in public transit (SEPTA in Philadelphia), where lapses in basic safety processes could, and did, result in bloody train wrecks.

Perhaps some whose sole experience with indolence and incompetence-driven catastrophe has been in discussions over coffee in faculty lounges cannot appreciate that viewpoint.

Academic organizations like AMIA could do, and could have done, a whole lot more to help reform this industry, years ago.

-- SS


Anonymous said...

And the proposed MEDTECH Bill seeks to exempt EHR devices from the purview ofbthe F D and C Act.


Anonymous said...

What's a "human factor?"

Jon Patrick said...

The term User Centred Design (UCD) will not of itself solve the problems of the clinicians as the power to choose what will be included resides with non-users. What is needed is User Controlled Design (UConD) where the user can specifically require what has to be included in the design.
This will raise a roar of complaint from software vendors that they couldn't possibly operate under such constraints. This is probably true for the dominant Health IT technologies in use today but is not necessarily true for the modern technologies of the 21st century.
Until the established vendors move into the 21st Century HIT will remain deficient of its one redeeming feature, making work more efficient.
We need :Immediate Adaptability" of HIT to ensure that clinicians are able to control the behaviour of the systems they have to use to care for patients.