The EHR Squeeze: How Much Can You Get?

Every time I walk into an organization to do an assessment on how they are using their EHR, I feel like my clients all have the same thought:

“How do we get the most out of our EHR? There is a magical way to use this software more efficiently that the vendor isn’t telling us what it is.  What is it and how can we do it so all of our users will be happy?”

They all want their EHRs running at their peak level of efficiency.  Now, every tool has a maximum level of efficiency based upon how we define it.  For example, your car can drive you fast with low fuel economy or at a moderate speeds with higher fuel economy.  Are we getting somewhere quickly or spending the least amount to get there? Since an electronic health record is a tool (not a solution, not magic) it also has a maximum level of efficiency based upon the goals that your organization has.  The point of friction, much like in the car/fuel economy example is when competing goals come into play.  But before you go and start defining efficiency for your own organization (which you should do before you implement an EHR), know this: If you want to get the most out of your EHR, don’t focus on making your EHR more efficient.

In truth, a user’s feeling toward the system isn’t just about efficiency.  It also includes 4 other factors that make up the idea of Usability or the quality of a user’s experience when interacting with a product or system.  These factors are:

  • Learnability – how intuitive is the system or how steep the learning curve?
  • Efficiency – in physician terms of EHRs, how many clicks does it take?
  • Memorability – if you came back to the system later, would you remember how it worked?
  • Errors – when trying to accomplish a task, how easy is it for the user to make errors?
  • Satisfaction – how content is the user after completing the task within the system that the job was done well?

It can certainly be shown that the number of steps it takes to complete basic tasks and the mental burden those require greatly affect usability.  But, there is an illusion that tweaks to a template or other minor system changes is the solution to this.  It isn’t.  The number of clicks a user has to take in a system to accomplish a task is largely determined by how the vendor designed the software.  I’m referring to software coding and design.  Some vendors have used the term “design” to suggest this is what the customer will do with their product after they get it.  Content building is not design.

When making changes to a template, you’re generally dealing with <5% of the problem.  Once a user learns the template, decreasing their total click volume from 150 clicks to 145 doesn’t really change things.  You don’t have control over the other 145 clicks.  This brings me to one of two factors of usability we can positively affect though: Learnability.

We can’t change the intuitiveness of the system much at all.  Again, that burden lies with the vendor, but we can attack the learning curve.  Most organizations only plan for a single training period for their users which will be completed before the Go Live date.  This is not enough.  A re-training should be scheduled for 6-12 months after the Go Live date (maybe sooner for some users) to go over the basic functions in the system and the problem areas the user is having.  If the user has tackled the learning curve gracefully, perhaps you can move on to some of the more advanced features (keyboard shortcuts, advanced user builds, etc.).  After that, a voluntary group training should be held regularly.  This is the best way to make sure everyone is aligned in how they are doing things in the system and also where users can share tips with each other about overcoming hurdles.  One of the biggest complaints seemingly for every EHR is the ability to find desired information easily.  Unfortunately, this requires the user to leap over the learning curve, but you can assist them with training and re-training them.

In a sense this also tackles the factor of memorability.  To take it a step farther, users should have quick access to reminders on how to accomplish basic tasks.  These “maps” can be either in print or intranet-based, but can supplement the lack of memorability that most EHRs have.  The combination of re-trainings and maps will reduce the amount of time a user spends with their EHR tool each day because you are making them more comfortable with it and giving them the knowledge of how to accomplish the jobs they need to get done utilizing this tool.

Perhaps most importantly is that this isn’t an initiative of the IT department necessarily.  A user’s ability to use the tools available to perform their jobs is really an issue of quality management within the organization.  Clinician led re-trainings are most effective because you have an example of someone successfully using the system day-to-day showing how they do it.  We like to ask how we can change the tool to make improvements and that really is a very good question to ask and work with the vendor on.  If you want results in the shorter-term though, we have to accept the tool we have and get the most out of it by adjusting ourselves to the tool, not the other way around.

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