Ross Koppel: EHR Problems

Three broad families of problems in EHR usage are identified in [1]:

1. Data Standards – the format one uses to record the collected medical information:

• There were several available ontologies and data standards for defining almost all of the measures used in medicine in 2009. We could have chosen one and insisted that any system that could receive incentives and subsidies had to use that data standard. Without data standards, interoperability becomes almost impossible. Of course, there could have been a flexibility built into that process. For example, any system could be installed in 2009–2010 but that system had to incorporate the unified data standards within a year.
• … without unified data standards we cannot share information across systems; we fail to achieve real interoperability. The systems create towers of Babel and those towers become isolated from each other; a noisy but deaf city.

2. Interoperability: sending information from one system to another:

• The problem of interoperability has been mastered in electronics and almost every other industry for over 40 years, often for several hundred. The major barrier in HIT was the aforementioned lack of a unified standard and the refusal of vendors to select a method of data transmission. Again, selecting any of the available methods in 2009 would have enabled the transmission and collection of medical information – a core, but still missing virtue of HIT. Several arguments are offered for the industry’s inability or refusal to create its own interoperability protocols or for its lack of agreement on existing interoperability protocols:
• Vendors benefit from sales of entire suites of products …. By not allowing a vendor’s software and/or hardware to interact with other vendors’ systems, a vendor ensures sales of a combined package.
• Because these systems are so expensive, because implementing them is three to five times more than just the initial software and hardware costs, and because the implementation process takes 3–5 years, opportunities for buyer remorse are limited or made unacceptable. The buyer is locked in; often wed to that system for a decade. The vendors thus seek to capture market share as soon as possible, and are encouraged to rush HIT products to market before they are sufficiently tested. … The vast funds involved, and the consequential career implications of those participating in HIT purchases enhance intimidation of critics and those who report problems with the technology. The general faith in technology and the sincere desire to see HIT improve medical workflow encourages so many to define critics as technophobes, incompetents, and non-team players.
• Data loss threats: lack of interoperability makes switching HIT systems perilous, with dangers of massive data loss, which would be a catastrophic failure for healthcare institutions. … As with data standards, the ONC could have offered flexibility in the timing of an interoperability requirement. Thus, for example, any system would be acceptable to purchase in 2009–2010, but all systems would have to be able to use an agreed-upon exchange protocol within a year of installation.

3. Usability: defined as ease of use, ability to learn, effectiveness, efficiency, error tolerant, engaging, and responsive.

• HIT vendors have agreed that usability is dependent on:

The training and skill of the user

The implementation of specific systems in specific settings

The history of HIT use in any setting and by any user

The relationship of a specific system to the other IT systems with which it must interact

The physical environment (e.g., lighting, noise levels, quality of display screens).

• All of these factors absolutely influence usability, often profoundly. But none of them should be allowed to obscure the reality that usability is intimately dependent on the design of the system. Moreover, none of these factors means that usability is not measurable. Indeed, there are well-documented scientific methods for measuring usability, including measures that incorporate and acknowledge the other factors that affect use. As a thought experiment consider automobile safety. No one would deny that a car’s performance and braking ability are influenced by road conditions, the driver’s skill, and the driver’s alertness. Yet it would be absurd to insist that basic automobile design decisions do not seriously affect a car’s stability, safety and braking effectiveness. In contrast to the automobile analogy, HIT vendors have, until recently, defended their lack of focused attention on usability by reiterating the mantra that usability is subjective, too theoretical, or essentially unmeasurable. Some vendors have claimed that there is only scant proof of the relationship between usability and safety. At the same time, and apparently without irony, several vendors also note they have employed usability experts and that their own tests find their systems to be very usable.