It works perfectly - I just can't use it!

In my recent post, I identified five hotspots which have developed in our national healthcare IT infrastructure. In today's post I will focus on Hotspot #2 - Usability / Patient Safety.

(I haven't forgotten #1 - I'll circle around to come back to that hotspot in a future article.)

It is widely acknowledged that usability is generally sub-par across the wide spectrum of EHR software in use today. The problem stems from complex, nuanced data on one hand, and the relatively quick pace of workflow in most clinical environments on the other. Add in the quick pace of development over recent years, and we're currently in the midst of the perfect storm in terms of usability. Given the nature of EHR software, problems of usability go beyond issues of personal operator convenience, extending to create conditions which could impact on patient safety.

I'd like to address two factors which have impacted on EHR quality over recent years.

The first factor is one which will adversely impact usability for almost any engineering exercise; the failure to account for conditions external to the boundaries of the system itself. In simple terms, for EHR developers, the primary items external to the system which must be taken into account during design and development are the users who will be using the software, and the conditions under which the software will be used.

When users and their working conditions aren't taken into account, whatever is produced (software or otherwise) may work perfectly within the boundaries of its own definition, but be manifestly unsuitable to its use in the real world.

Consider the following spectacle: (We can't call these spectacles, because there's only one lens!) The optics are flawless and the photochromic response to UV rays works perfectly. The frame is durable and stands up to being dropped from a height of 10 feet onto a linoleum surface 1,250 times.

This spectacle works perfectly but is completely unusable because beyond its own boundaries, it simply can't be used in its current condition! Sad to say, sometimes software is released in similar condition. It works by its own definition, but it's difficult to use.

Vendors must take responsibility to address this particular issue. Attention to the user experience, and the adaptation of the software into the environment in which it will be used, is a critical component to the process of creating software which is both functional and usable.

Beyond this however, there is another major factor which is impacting the usability of today's EHR applications.

I'm late! I'm late! For a very important date!

Earlier this year, I was among a group of vendors who delivered testimony on the subject of Meaningful Use Certification before the Health IT Policy Committee. The first day's testimony is available here and the second day's workgroup discussion is available here in both transcript and audio formats.

A common theme which emerged from the collective testimony was "too much work, not enough time".

Under these conditions, software quality and usability are going to suffer. It's simple cause and effect. Software production is inevitably constrained by that well-known engineering triangle. Productivity = Resources multiplied by Time. Here's how this equation plays out in the real world:

For most vendors, the pool of resources is relatively static. It's not that easy to simply throw new developers into a project in an effort to accelerate its completion (Brook's Law).

The project deadline is immutable, as per legislation. (At least that was the presumption until CMS issued its late-breaking NPRM on May 20, 2014. This didn't help software developers since in almost all cases the development phase was long since completed and vendors were already shipping their MU 2014 Edition software by the time this NPRM was published.)

With insufficient resources, and not enough time, productivity is inevitably going to be impacted. Features can't be adjusted since the featureset for a certified EHR is precisely defined. The only aspect of development which can be cut is quality. When quality is cut, both usability and patient safety are adversely impacted.

Future stages of Meaningful Use need to take this reality into account. Stage 2 was much too broad, with not enough time for development.

Future stages should place emphasis on those aspects of EHR technology which are the drivers for the most important improvements to our current health IT infrastructure. These are:

1. Interoperability
and
2. Quality Measures

The hallmarks of future stages should be:

1. A concise set of focused criteria (i.e. the 'theme' for a particular stage)
and
2. Sufficient time to effect enhancements to the desired level of quality

CMS and ONC have demonstrated that the Meaningful Use program can be a driving force to spur advances in health IT. We need to see some degree of moderation though, so that for their part, vendors will be able to keep pace without sacrificing the high standards of usability and safety which are critical to the quality of our national healthcare IT infrastructure.