The era of first movers in the EHR space has established itself in our healthcare system leaving tens of thousands of clinicians burned out, frustrated, and defeated. Epic, Cerner, and Athena, have emerged as major market players in the US and international EHR market. Epic alone is worth nearly $4B (though that does seem low for perhaps the most dominant player). These companies and their products benefited immensely from being in the right place at the right time. Yet, nearly universally, clinicians complain about these products (to varying degrees). Jokes, complaints, and gripes abound about the poor UX of these incumbents. Yet I don't believe these assessments are fair. Primarily because the companies don't need to worry about UX.
Early movers in any industry don't need to worry so much about UX because they're the only ones doing what they do. The decision to adopt a piece of technology for any business is an easy one when there are no other options that can fit that use case. User happiness, effectiveness, or efficiency, the bread and butter of UX metrics, are not a priority for most businesses because those metrics don't directly effect the bottom line (in an obvious way). This is particularly true in healthcare, where complex incentive structures related to Fee For Service billing make it so that IT teams and CFOs are primarily concerned with minimizing the cost of delivering care while maximizing profit. Unfortunately, user efficiency, happiness, and effectiveness don't make it very high in the inevitable priority lists that great created at the C-Suite level.
In a post-HITECH world two things happened. Many hospitals, physician groups, or independent practices naturally gravitated to using the only options available on the market, Or, they were priced out of using those options altogether and subsequently closed.
We are now seeing unintended consequences of the HITECH Act. Physician burnout, care consolidation, and care costs are all increasing while care quality continues to decrease. This is due, in part, to EHR impacts on the people who deliver care. Over use of copy paste is just one example of how bad UX has impacted patient care, possibly leading to a clinical error. In the market, independent physicians, once the cornerstone of community health, are priced out of owning a practice. Hospital systems or private equity firms buy these practices, practices are transformed into RVU printers and voila — choice, options, and community empathy are removed from the equation. The people most directly affected are the ones delivering care and their patients. Shareholders, executives, and investors see it as a triumph of modern capitalism at work in our healthcare system.
Many smart, talented, and passionate people have put forward a litany of solutions to these problems. Abridge, Canvas Medical, Patient Ping (now owned by Bamboo Health), recently announced Doximity GPT, and many others are building interesting solutions that focus on making the end user experience better for clinicians and patients alike. Either through targeted application of AI or smart new design patterns that align with clinician workflows in specific areas that the tool can own. Yet, in many situations they are still hamstrung by the vice grip of EHRs on the "digital infrastructure" of healthcare.
So what does design or UX have to do with any of this? All of these problems should be in the hands of healthcare executives, highly paid consultants, or healthcare MBAs, right? Wrong. The best way to think of this is by understanding the component parts of what goes into building software. Engineering, business, and design working together to build an innovative, differentiated solution in the market. Ryan Rumsey states this beautifully by showing these three disciplines as a connected system.
I will humbly, add one new discipline to this. Medicine.
Design makes something desirable. Something that customers want to buy and users want to use. Design isn't just about how it looks, but what it is, how it fits into a user's workflow, and helps them do their job. Yes, the ultimate deliverable is a thing to look at and interact with. But great design, and specifically great design in EHRs has to start with workflow, function, the job, the day-to-day of users, the companies they work for and their incentive systems. Through it all; a focus on partnering with clinical, engineering, and business to ensure that the product is worth using and building.
I have heard from many physicians about how they wish EHRs were easier to use, simpler to understand, or better designed for their workflows. The complaints are endless that many EHRs feel stuck in the 90s. What they are ultimately describing is a product that they do not desire. Add on to the fact that their compensation, professional development, or career stability are tied to the data collected by EHRs and it is easy to see how the EHR contributes to high levels of burnout, frustration, and exhaustion.
So the question is, how does one make an EHR more desirable? But importantly how does it also remain feasible and viable within the world of medicine?
I've found that designing with clinicians is just as much about identifying their issues as it is to actively listening to them. Many physicians feel locked out of the product development process for their current EHR offerings. Even if they don't realize it, they often feel that the people who build the EHR they use don't know them and what they need. Many times, research calls often seem like a form of therapy for the clinician. Having an EHR designer and builder who actively listens, solicits feedback, and implements that feedback is a huge win over other incumbents.
Building software for the business of healthcare can feel completely contradictory to the needs of the clinician. Many care businesses (a term I'll use to loosely represent any care organization that isn't an independent physician) operate on razor thin margins and struggle with many aspects of delivering care. EHR vendors must be more in tune with the challenges of running these businesses and work to meet them where they are while honoring the frustrations and challenges of clinicians. This can be prioritizing light, quick launches that have zero or little down time for the practice, building intuitive back office automation tools, or simply helping practices position their EHRs as an advantage.
P.S. — As clinicians choose to to do other things with their skills and talent instead of delivering care, I believe good UX will become a differentiator for care organizations to attract and retain talent.
"I need it to be more flexible for my workflow." A near direct quote I've heard from many physicians. This challege is perhaps one of the biggest that EHR designers face. Endless flexibility does not lend itself well to the world of strict-linear workflows that most interaction patterns are designed to enable. Most menus, steppers, forms, and tab controls are designed to constrain a user into a particular sequence of steps or actions.
The more complex the care environment, the less standard the workflow that the physician will have. Thus, traditional design patterns won't be successful. I think we have to think modularly and break down clinical data into it's core components that can be represented consistently and cohesively to serve the clinician where they are. Ultimately what this comes down to is helping clinicians and IT teams rethink what "work" and "productivity" means when translated to an EHR. No longer should we think of work being about managing a single workflow but rather about managing the "work" of delivering care.
No matter what we do, software for clinicians will inherently be complex. The scope of data that physicians need to consume, analyze, and make decisions on is vast and ever changing. Thus I believe an EHR design should be designed for clarity first. This means minimal use of colors, font sizes and weights, minimal line separators, and a judicial use of space. This creates clarity and focus for the user. The system isn't just architected to be modular it is literally designed to remove distraction and increase focus for clinicians.
I interviewed a physician maybe a year or two ago and when we started talking about terminology in the UI, he said "My current EHR uses the completely incorrect language. it's like they've never talked to a physician." (I'm paraphrasing but you get the point). This was a huge wake-up call to me. Clinicians are extremely detail oriented people and the practice of medicine requires an immensely in-tune sense of detail. pattern recognition, and problem solving skills. The details that go into an EHR must align with the user's skills. Button labels, names terms, abbreviations, and many other pieces of text must be accurate, clear, and understandable. And UI components representing data, timelines, imaging, and many others must be consistent and detailed to give the user what they need when they need it.
One might expect this article to end with a sales pitch or a manifesto about why my product is the one that will accomplish all of this first, best, or fastest. The truth is, I don't have much of a stomach for such promises, pitches, or superlatives. I'm not a particularly good salesman and while I have grand visions and plans, they are just that – visions and plans. No, the purpose here is to lay out what I believe will be defining characteristics of the next wave of EHRs that are successful.
An eye towards design doesn't just mean that the software will look better. Though that will have a big impact on users' impressions. No, it means that clinicians and their employers alike will want to buy, implement, and use the software. It will represent a shift in making physicians into true partners with their computers. A shift that will free up clinicians to focus on the parts of their job they want to do. Problem solving, taking care of people, educating patients, or opening their own practices.
Design will define the next wave of EMRs and those EMRs will define the future of healthcare.