HIT Perspectives: Lack of Training is Core Cause of Physician EHR Usability Complaints

You hear it all the time: electronic health records (EHRs) are proliferating, yet doctors allegedly hate them because of usability issues. As a product manager, I’ve been the recipient of many a tirade from an unhappy physician client saying, “It’s not intuitive,” or “There are too many clicks,” or “Why can’t this be as simple as an iPhone?”

Physician disdain for EHRs has been expressed loudly and often enough that regulators have included usability testing as a certification criterion for EHR incentive programs. Consequently, everyone is searching for underlying causes. Some studies have already tied usability issues to physician burnout. Now a new study has determined that lack of training impacts physician usability perspectives.

EHR usability problems. EHRs are certainly not perfect. Software improvements can be made to tighten up the user interface (UI) to be more logical and reduce the number of clicks. Soliciting user feedback through usability testing is a valid and reasonable mechanism for prioritizing EHR enhancements, though I’d stop short of mandating it. A software vendor that doesn’t pay attention to customer feedback about its product’s usability is doomed to fail the old-fashioned way – customers simply won’t buy it.

EHR vendors face a significant hurdle regarding usability. Because of its inherent function, an EHR simply can’t be as easy to use as an iPhone. A UI that’s perfect for Instagram and Twitter isn’t practical for a task as complex as documenting the patient visit of a 72-year-old with comorbidities.

Equally challenging is finding the right balance between what information a clinician would like to see and how much is too much. In this regard, medicine is as much an art as a science, with each clinician having his or her own preferences. For this reason, EHRs are designed to be flexible in order to accommodate the unique style of the individual user. This has led to some of the resulting dissatisfaction because with flexibility comes lack of consistency. Time and again, clinicians have claimed that their practice is “different.” Yet what perpetuates the usability challenge is allowing insufficiently trained clinicians to use the EHR “their way” and ignoring the best practices (i.e., consistency) gleaned by trainers across thousands of implementations.

EHR training is a constant tug of war. Because EHRs are necessarily complex, education is essential. Unfortunately, it’s often difficult for clinicians to set aside time for such in-depth training. Clinicians are among our best-trained professionals, having spent years of study in medical school. While clearly recognizing the value of proper training, they somehow fail to perceive learning about EHRs as an investment.

In my 12+ years’ tenure as an EHR product manager, my experience with the correlation between training and satisfaction has been anecdotal. No real statistics exist to validate what I’ve learned from the college of hard knocks – that insufficiently trained clients are dissatisfied clients.

Shedding light on the problem. Now we have data to illuminate the problem. A recently published study (72,000 clinicians at 156 provider organizations) by the Arch Collaborative has examined EHR satisfaction. Its conclusion: “If health care organizations offered higher-quality educational opportunities for their care providers, and if providers were expected to develop greater mastery of EHR functionality — many of the current EHR challenges would be ameliorated.”

Across this extensive dataset, the study notes that “the single greatest predictor of user experience is not which EHR a provider uses or what percent of an organization’s operating budget is spent on information technology, but how users rate the quality of the EHR-specific training they received.”

These are telling statements that highlight the challenges EHR vendors face regarding client satisfaction. With as many as 30% of practices looking to replace their EHRs, one wonders if their experience with a new EHR will be any better without a commitment to training. They also explain why EHR vendors that impose prescriptive training requirements are perceived as having a better product when compared with those that allow their clients to dictate the training curriculum and requirements.

These also help to explain why many of the advanced features that EHRs offer are underutilized. Population health comes to mind. Clinicians who are frustrated by clicking their way through poorly configured workflows that require bouncing from screen to screen aren’t going to be receptive to messaging about evidence-based best practices. Instead, they’ll succumb to alert fatigue and ignore every message as an interruption. Population health DOES work when well-trained clinicians breeze through optimized workflows that sequentially match the patient exam. Actionable population health information interspersed within such a workflow is unobtrusive and valuable. Instead of being an interruption, population health becomes a component of clinical decision making.

Opportunities. The conclusions of this study create some opportunities. Organizations, such as pharmaceutical, medical device and medical services companies, working with clinicians using an EHR should be prepared for workflows that differ from client to client, even those using the same EHR. They should be aware that client staff using the EHR may not have received (or paid attention to) the in-depth training offered by the EHR vendor or that workflows in place may not have been optimized. Coaching that incorporates those best EHR practices emphasizing fewer interruptions and actionable information will be welcomed by clinicians.

Point-of-Care Partners are experts in EHR workflow. We can help your organization better prepare for discussions with clinicians about EHRs, including best practice workflows. Let me know how we can help. Please contact me at michael.burger@pocp.com.