Response to EHR Guy posting on Contextual Usability in EMRs

The EHR Guy posted an interesting topic for discussion at the EHRNET called “Why is Contextual Usability so Important for EMR Implementation Success?” I encourage readers to visit that forum to add to the discussion if this topic is of interest to you. Below is The EHR Guy’s topic posting and my response to get an idea of whether this might be worth discussing further.

The original topic by The EHR Guy 13Mar2010

Why is Contextual Usability so Important for EMR Implementation Success?

EMRs fail after a short period of time from their initial implementation.  Most get removed leaving a sour and bitter taste on the tongues of both vendors and buyers.

Many well intended software designers do not understand the different settings a clinician deals with during their daily workflow and they end up building good software but unusable in a practice or clinical environment.  Most vendors don’t listen to their consumers or simply don’t understand what they are saying.

Modernizing healthcare IT will be a great endeavor for the next decade and it will also be a monumental challenge.

Understanding the Contextual Usability of software in a clinical space will be key in developing technology that is adept to the needs of the users.

How many of you have designed software and devices that take into account Contextual Usability?

The EHR Guy

Here was my initial response on 13Mar2010

Reply by Dr Robert Schertzer 


Great issue well worth discussing. One of the least understood areas for most EHR developers seems to be a lack of understanding of the specialist physician's clinical practice. Our history and physical examinations tend to be quite focused on a few aspects of the patient in great detail. Then, often based on pattern recognition of a constellation of findings, we come up with a single diagnosis, tests needed to confirm and a treatment and follow-up plan. The next step is generating a consult report back to the referring doctor, copy to the family doctor and arranging the follow-up tests and visits. Good luck finding an EHR to fit your needs.

I developed an EHR in 1994-95 during my glaucoma fellowship at Dartmouth Hitchcock Medical Centre using FileMaker pro with my colleagues Luanna Bartholomew, David Pang and David Campbell. Its strength was the detail it provided related to eye examinations and was even able to generate the consult letter. Once I saw other EHR solutions that I did not have to support myself, I was happy to not have to complete the project. That being said, it was only a couple of years ago when I finally found a solution that works to meet all the criteria I listed above including the billing, scheduling, report generation, graphing of lab results against medications over time using Optimed Software's Accuro.

In the years between 1994 and 2010, I have been through several EHRs in search of one that meets my needs as a sub-specialized ophthalmologist. Two EHRs back, the vendor had scheduling a billing and a promise that went on for too many years to provide history and physicals (in fact, many years before they moved from DOS to Windows.) The next EMR was designed by an engineer who watched his brother, who was an optometrist, as he worked and this fits in well with this discussion. This was somebody who actually looked at the clinical use to figure out how best to make an EHR. This VisualEyes program by iiiiSoftware did a great job but it's main shortcoming a few years ago was in the format of the letter generation. In addition, it was not designed to track what medications a patient is taking or their surgical history. Back then, it was restricted to exporting all the history and physical findings into two columns filling three pages. This is because although the clinical setting was taken into account, and it was eye doctor related, it was not a consultant ophthalmologist that was consulted. We need that easy ability to generate consult reports and know that no referring doctor wants to sift through 3 or 4 pages listing every single finding until they get to the bottom line.

So, with input from clinicians, I totally agree that EHRs can be much better.