The medical field is in the midst of a major transformation, fueled by a combination of legislation and rapid adaptation. This trend has been most apparent in the rapid expansion of telehealth. A review of 16.7 million medical visits conducted from January to June 2020 revealed a staggering 2,000% increase in telemedicine visits. For some of my patients, this ability to conduct a visit through their computer or smartphone has been life changing. It is clear that the Covid-19 pandemic, despite providing some of the toughest challenges, has also brought out some of the best traits in healthcare organizations: agility, adaptability, and innovativeness.
However, we still do not know the full impact of telehealth. Will it be good for patients? For some, it will mean access to care that would otherwise be impossible because of limited transportation, excessive distance, and other prohibitive costs. But the risks, including potential for missed diagnoses and physical exam findings, remain a concern. Will it be good for providers? For some, it will mean the convenience of not commuting into the office and the peace of mind of working remotely during a pandemic. But a study over a million e-visits revealed that the adoption of telehealth nearly doubles the number of work hours per week, with the bulk of work occurring on nights and weekends, while questions about telehealth’s implications for malpractice claims remain. Of course, the telehealth explosion was born out of extreme necessity. But if necessity is the mother of invention, is all invention good? The answer may depend on how we envision success.
Path of least resistance
This tension can be seen in the evolution of the electronic health record (EHRs). Despite their promise, early adoption of EHRs was limited due to the technology’s high costs and low usability. The Health Information Technology for Economic and Clinical Health (HITECH) Act set out to fix low utilization through legislation. And, it succeeded — by 2017, 96% of U.S. Hospitals had adopted certified EHRs. But an unintended consequence of this rapid adoption was that EHRs, which were originally conceived as catalysts for improved patient care and physician wellness, instead became a major source of physician distress. This phenomenon was described in a recent study assessing the usability of EHRs through the System Usability Scale (SUS) — a validated instrument designed to measure the effectiveness, efficiency, and satisfaction with an electronic system. Google’s search engine has an A rating; a microwave or an ATM has a B rating. But 10 years after the passing of HITECH, EHRs are still being given an F grade by the primary end users — physicians.
More importantly, EHR usability is highly correlated with physician burnout. “It is no accident we are where we are now,” says Dr. Ted Melnick, director of the Yale Clinical Informatics Fellowship and lead author of the study. “The HITECH Act incentivized rapid adoption of EHRs. In order to qualify for federal incentives, EHR vendors rushed products to market. There was no time for health IT to organically address usability and the user experience. Now, here we are with powerful yet clunky systems that have digitized healthcare at the expense of the clinician-patient relationship.”
Over time, EHRs have also become increasingly complex. With each additional need (e.g., compliance with billing requirements, increased patient access), the EHRs have expanded to include new capabilities. But the design of the tool has consistently lacked one key component: a cohesive understanding of how it would impact providers. Absent that focus, the evolution of these systems has followed the path of least resistance — the added responsibilities defaulted to become the burden of the providers. In this way, the issue is not that EHRs are imperfect; it’s that their imperfections disproportionally affects providers.
Ten years after the passage of the HITECH act, work at home and on the weekends — dubbed “pajama time” — has become an industry standard while physician burnout associated with EHRs is the industry’s worst-kept secret. Indeed, 70% of physicians who use EHRs report health information technology (HIT)-related distress. And if the intention was to improve satisfaction with the physician-patient interaction, then those results have yet to materialize. In fact, time motions studies reveal that physicians spend twice as much time with their screens as with their patients. Essentially, by rushing to implement a solution, healthcare was opening a digital Pandora’s box, spending the next decade in an attempt to put the plagues back in the vault.
The digital communication revolution
Recently, the digital communication revolution has been kicked into high gear in healthcare, driven by attempts to increase patients’ access to their providers and medical information. The most widespread example is the patient portal and the in-basket — a tool through which a patient can send a message directly to a provider’s inbox. The emergence of patient portals and direct-to-provider messaging has exacerbated the expectation of instantaneous availability, making it increasingly difficult for providers to truly “log off.” It is no surprise that receiving an above-average number of in-basket messages has been associated with a 40% higher probability of provider burnout. Dr. Christine Sinsky, VP for Professional Satisfaction for the American Medical Association, explains that the in-basket puts two strains on physicians by creating “expectations that they be available 24/7 to their patients and the requirement to work after hours simply to get work done.”
She proposes a radical redesign of our current processes by concentrating on several key factors: setting clear expectations about when and how providers must be available; and team management of the inbox. EHRs are a powerful, but novel, tool. Developing cultural norms around their use is key to managing expectations. Meanwhile, engaging nurses and medical assistants in managing the inbox can be vital in helping triage questions that need to involve the provider versus those can be managed without them (for example, forwarding a prescription from one pharmacy to another). This step requires a well-resourced and stable team and continuous training. But as before, we are finding ourselves playing catch-up and trying to undo the conceptual design flaws inherent in both legislation and the EHRs themselves.
From chatbots to intelligent EHRs, promising new technology could help alleviate some of providers’ workloads. But even as we work to decrease the inbox load the central question lingers: should we continue to rush products and legislation to implementation without putting measures in place that protect our most valuable, and often most fragile asset — healthcare workers themselves. Dr. Ratwani, Director of the MedStar Health National Center for Human Factors, sees this as one of the central questions of innovation in healthcare: “New digital health technologies offer tremendous potential. However, in order for these technologies to lead to the patient outcomes we all desire they have to be designed, developed, and implemented with patient and clinician needs in mind.”
In healthcare, the coming years will be defined by ever-more sophisticated EHRs, increasing digital access by patients, the explosion of personalized medicine, and widespread adaptation of artificial intelligence. All will be indispensable tools in the new era and all still carry many unknowns. Ensuring that these tools serve their intended purpose will require us to think beyond the path of least resistance. Instead, new interventions must involve deliberate design that considers the impact of innovation on all the main stakeholders, including providers. Ted Melnick points to six core tenets of HIT design that can help ensure its success:
- Put patient care first: Remembering this core goal of HIT can help ensure it remains safe, effective, and efficient.
- Assemble a team with the right skills: Successful design will require the input of a variety of perspective and skillsets. A careful interplay of experts in human factors, finance, population health, and provider wellbeing, among others, will be needed to ensure that innovation is functional, sustainable, and supports various stakeholders.
- Relentlessly ask why: Asking why things are done a certain way can help ensure that HIT does not get stuck in a cycle of “we do it this way because that’s how we’ve always done it.”
- Keep it simple: Using human factors principles can help lead to intuitive and user-friendly design.
- Be Darwinian: Test innovation and only keep the best features at every stage.
- Don’t lose the forest for the trees: Assess the potential unintended consequences of human and technological interactions with each design modification.
- Troubleshoot problems, not solutions: Often, healthcare design fixates on bolstering solutions before identifying the real problems. At each step of process design, it is important to reassess what fundamental issues the proposed solutions aim to solve. This can help avoid the pitfall of solutions for solutions’ sake
Finally, it is essential to remember that healthcare technology does not exist in a vacuum. As such, it should look to other industries that have successfully implemented user-centered design. After all, with over 40% of physicians experiencing burnout, too much hinges on getting it right.