There's a tremendous irony about ARRA/HITECH. It comes in the form of non-goals.
Along with the clearly identified need for EHR technology to improve our healthcare delivery system came some concurrent observations, i.e. need for the current EHRs to improve. A recurring, big observation was that the user experience (the GUI, the number of clicks, the ease of use, the intuitiveness, etc.) of all EHRs, commercial, homegrown, and OSS offerings, were way behind that of the user experience for mainstream commercial applications. Many consumer Web sites are an absolute pleasure to use, and highly effective. Google, Amazon, and others will give you what you want, in addition to what you actually ask for. They'll correct your misspellings and make you aware of relevant options, based on the experience of other users with apparently similar intentions. (This is accomplished, of course, with zero human build work, and maintained in real time.) They've transcended a focus on automated basic workflows and associating decision support with process automation. They prefer to collect (with opt-out, of course) personal information. What do you commonly do? How do you seem to prefer to do it? There are often three or more options for how to get from here to there. If you try something reasonable, it's been thought through and will often work. If not, you're likely do get a "did you mean ...?" option. Most of us, as a result of these modern consumer user experiences, have more books (from Amazon.com), and perhaps many unread books, throughout our homes, because browsing and one-click ordering are so darn easy.
Modern consumer user experiences are a great thing. We can read and write (interact) news through newspapers, online everything, and of course, blogs like those at HCI. Wouldn't it be great if we had similar fluency with our healthcare information? As nurses and doctors, of course. And as patients, of course.
Instead, what we experience today is considerably more dated. My physician, for example, recently sent me the results of
my labs. He went out of his way to personalize the results with a handwritten note. That's nice. He's on one of the most popular ambulatory EHRs and has been for over five years. For at least three years, his group has had the most sophisticated ePrescribing solution integrated with its EHR. Here's where things apparently break down badly, relative to a consumer experience. The lab results are apparently not integrated, as suggested by the lab report he sent. The report is almost completely naive to my problems, medications, allergies and key clinical trends. Is my LIPID PROFILE getting better or worse? What, if any therapies are concurrently associated with these therapeutic results. Not clear from the printout or the handwriting. The note was subsequently scanned into the EHR. Again, this is one of the most automated practices in my area. They made the EHR investment years ago, and have stayed up to date with their releases.
With ARRA/HITECH, all vendors, both ambulatory and inpatient, have had an extremely strong incentive to stop developing according to their roadmaps, leading in part to more consumer friendly features like showing new lab results in the clinical context of problems, medications, and key trends. Most readers appreciate that this suspension of innovation is necessary and ultimately a good thing in order to gain the benefits of certified products and establishing a meaningful use threshold. That said, the work to deliver the consumer grade experience has clearly been put on the back burner.
I think this disciplined prioritization (i.e. the current certification and MU process) would be healthy if we were talking about it in public. Hence, "Non-Goals" statements. Some people of course are being very candid and honest with HITECH. Watch
Anthony Guerra's VIDEO BLOG and
download his paired slides. But Anthony is the exception. Many policy makers are simply disingenuous. They encourage rage by suggesting CIOs think the current, state of the art EHR is great. Instead, they should follow the lead of economist Michael Mandel, below, that ARRA needs to be part of a multi-phase deployment. And, we acknowledge that consumerization cannot and should not be in phase one.
On the technology side, achieving the rich, consumer-grade experience in the Web world requires technologies like Adobe's popular Flash. Another related emerging Web technology, WebKit, is a layout engine that supports advanced ways to render Web pages to create a richer user experience. In reading the main WebKit page (insert link), I saw a clear list of goals. But perhaps more importantly, it was followed by a list of Non-Goals. What a wonderful way to set clear expectations!
There's an interesting parallel to this one-two sequence of EHR policy reform. One, standardize the platform, then two, innovate on the experience. In healthcare economic reform, according to BusinessWeek chief economist Mike Mandel, you've got to solve the healthcare coverage problem before you address the cost problem. Otherwise, you'll just have massive cost shifting resulting in unmanageable coverage worsening. The Dems are better politically positioned to take on coverage; the Republicans, the cost. That's according to Mandel. If there's a similar fate for EHRs, the Republicans will be the party to bring consumerization to EHRs, since this must be a non-goal as we focus on basic coverage. That's certification and meaningful use. December, 2009. Coming to a state near you!
