Defining the human factor in EHR efficiency

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Two informatics experts attested to the need to make elements of electronic health records (EHRs) work for people, instead of the other way around, at the HIMSS 2007 conference in New Orleans yesterday.

Boston-based Partners Health System has a home grown Web-based health record system which they call Longitudinal medical record (LMR) which was launched in 2002. Qi Li, MD, MBA, clinical informatics research and development at Partners emphasized in his presentation that these types of systems must have users in mind so that the full benefits can be achieved. Generally speaking, problems that arise within EHRs are sophisticated in that they are “not just software problems and not just people problems” and involve a number of elements.

The Partners system is utilized by 4,000 doctors. It was initially primarily focused on primary care but now encompasses community physicians and specialists. Realizing the complexity of finding the full potential of the LMR, Partners launched a usability study to further develop workflow efficiencies and boost productivity.

In doing such as analysis and evaluating the results it is important that you consider types of workflow that clinicians can adhere to for long periods, Li said. Otherwise the changes will not last for long.

This is crucial because EHRs, somewhat paradoxical solutions, are “a benefit for patient care, however, it adds time to patient care” at the same time, Li said.

Hence, invariably users are going to be challenged to “re-engineer” their clinical workflows so that the fit between user and software “will be extremely tight,” he said.

Throughout it is important that whatever the outcome, IT personnel should be sure to listen to user concerns and that solutions should be highly customizable depending on user preference.

Omar Santiago, MSc, MBA, of Massachusetts General Hospital, gave the example of doing an audit of both IT personnel and physicians as a good approach to get an understanding of both perspectives on EHR operation at a facility.

In this way you can get a clear understanding of issues, set priorities for ways to resolve workflow problems, and create better benchmarks for optimal EHR operation.

In the Partners study, it became clear after evaluating doctor feedback that there was a consensus desire to complete documentation either during or within 5-10 minutes of seeing patients. The problem is that physicians generally don’t have time to accomplish this, Santiago said.

One approach to resolve this problem was to begin measuring EHR performance by the system’s potential to enable physicians to perform all patient record review and documentation in seven minutes or less. This way they would actually use time as a measure for system performance, he said.

A second approach was to give physicians the goal of completing all documentation during the patient visit, rather than right afterwards. However, physicians felt they did not have time during a patient encounter to get all of that done.

Santiago said he took this as “a mandate to designers to give back time to clinicians” through system design. In order to do this detailed task analysis was done at Partners to specifically understand how physicians are completing their tasks. The analysis included mouse clicks, sitting positions during tasks, and other minute details.

This type of detail can uncover areas for potential improvements such as combining redundancies, reducing steps, mouse clicks, and screen refreshes which, though seemingly small, can do a lot to speed up workflow given the quantity of work being done.