As we implement EHRs, it seems we run into the same questions, and the same issues.

“Why is my EHR so hard to use?”

And we focus on physician training, and workflow analysis and redesign–and that’s all critically important, but in many ways we ignore the fundamental issue–that EHRs are software–they’re an electronic approximation of something else (and something we’re quite comfortable with)–a paper medical record.

And that’s the core of the issue–EHRs are a good approximation of a paper record.

But they’re not paper records.

There’s a reason why we like paper and pen, and why most of us still take notes using those antiquated tools–they work!

The problem is that computers are unforgiving–they’re on or they’re off, yes or no, ones or zeros–there is no gray. Everything is (and must be) black and white.

And the world (and medicine) simply do not work that way.

An example:

Think about ordering a diet for a patient.

Using a paper chart, a physician could easily order “Regular Diet” and all was well. A nurse would be able to interpret that order, and adjust the patient’s diet accordingly.

But with an electronic record, you might need three different “fields” to be completed–for example diet, texture and liquid modification. And those three fields would always need to be completed for a valid order to be place (remember, the computer only understands ones and zeros).

So now with an electronic record, every physician needs to learn and understand what “texture” and “liquid modification” mean, and the options available to them if they want to submit a diet order.

Now you can see why physicians initially balk at EHRs, and why they articulate their displeasure with phrases such as “An EHR slows me down” or “It changes the way I practice”.

Suddenly there are multiple new things that doctors need to know–things they didn’t even previously think about. And that’s especially disconcerting for physicians who’ve practiced successfully for many years.

So what can be done?

First and foremost, better software with better user interfaces. I’ve blogged about this quite a bit–EHRs are programmed by programmers. They write code (and design software) in a way that makes sense to them.

But they’re not clinicians.

And then we wonder why clinicians aren’t happy.

But that’s a long-term solution–the real question is what can we do now?

1. Education & Training- physicians need to know the challenges that are ahead. They need to know their world will change, and there will be new things they’ll need to learn. And yes, we have to admit they’re right–that EHRs will slow them down and change the way they practice. And they need to know there are solutions, and that success can be achieved with dedication, training and hard work. The difficult part (of course) is for organizations to adequately plan (and budget) for the time, staff and resources required to provide that training (but that’s best left for another blog post for an in-depth discussion).
2. Workflow Design – create new clinical protocols and policies that support order sets that “make sense” to clinicians. (i.e. implement “smart” systems that “know” what “Regular Diet” means–without having to complete unnecessary or redundant fields). Many systems can be configured to facilitate clinical operations, and vendors have often already solved these issues for other customers.
3. Encourage Innovation – not only for our organizations, but for our vendors. It’s a partnership, and that means that clinicians need to help vendors create better products and better interfaces (and not have vendors responding to our clinicians’ and organization’s needs).

Will we get there?

Yes–eventually (I hope).