A primary care physician may care for 2,500 or more patients in a given year, and many of their patient encounters may last only 20 minutes – much of which is often spent at a computer with a back turned to the patient.

It's become a truism by now that electronic health records are often viewed askance by primary care docs, many of whom see them as detrimental to the patient encounter. But a new report from U.S. Department of Veterans Affairs, Regenstrief Institute and Indiana University details just how outpatient EHRs are often failing the physicians who use them.

WHY IT MATTERS
The new study, Electronic Health Records' Support for Primary Care Physicians' Situation Awareness, contends that EHRs "are not rising to the challenges faced by primary care physicians because EHRs have not been designed or tailored to their specific needs," according to researchers.

The report, published in Human Factors, the Journal of the Human Factors and Ergonomics Society, draws on eight years of close study of EHR use patterns to argue for wider acceptance of "human factor approach for the design or redesign of EHR user interfaces."

Funded by the Human Factors Engineering Directorate in the Office of Health Informatics at the U.S. Department of Veterans Affairs, the study was led by Regenstrief Institute Research Scientist April Savoy, a health services researcher and human factors engineer.

As researchers see it, many EHRs as currently configured make it too difficult for primary care docs to do their job in a streamlined and efficacious manner – requiring navigation through multiple screens and tabs to find basic information, increasing redundancy and decreasing efficiency.

Something as simple as auto-save – a default capability for most online shopping, for instance – is missing from many EHR systems. As the researchers argue, it's sometimes "easier for consumers to search online and order a pair of shoes in a desired size, color and style, than for primary care clinicians to order a specialty consult or medication refill."  

The study traces the roots of the challenge to the fact that many EHRs were initially designed for specialists and hospitals – without much attention to the specific needs of primary care physicians, "whose effective decision-making is grounded in perception and comprehension of a patient's dynamic situation."

For example, they note, an outpatient doc's choice to stop a patient's use of a particular medication will usually be informed by trends in that patient's blood pressure or cholesterol numbers, or by other medications taken over the course of a month – all holistic information with implications for the patient's future health trajectory, but data that isn't always readily seen on a single EHR screen.

"The human mind can do many things well," said Savoy. "Digesting vast amounts of patient information while multitasking in time-constrained situations exposes a limitation. EHR technology should be able to complement or enhance physicians' abilities in these scenarios."

Instead, she said, "current EHRs are overloading primary care physicians with information in disparate files and folders rather than presenting comprehensive, actionable data in a context that gives meaning."

THE LARGER TREND
In addition to Savoy, researchers in this study included Himalaya Patel, Dr. Daniel R. Murphy, Ashley N.D. Meyer, Jennifer Herout and Dr. Hardeep Singh – all with the VA.

For the report, they reviewed and analyzed studies describing EHR workflow misalignments, usability issues and communication challenges. They noticed, for instance, that significant difficulties were reported related to obtaining clinical information from EHRs, with lab results and care plans often incomplete, untimely or irrelevant.

They also examined common clinical decisions and tasks related to care management of adult patients that are typically not supported by clinical decision support tools, such as whether to start palliative care, predicting quality of life and recovery time, and tracking progress toward patients' stated goals.

With their metanarrative analysis – more inclusive and open-ended than a meta-analysis – they found that primary care physicians' experiences with EHRs often included redundant interaction and information overload.

This could be remedied, they said, by incorporating more user-centered design principles into future EHR design, development and evaluation.

ON THE RECORD
"Technology needs to adapt to humans' needs, abilities, and limitations in healthcare delivery as it has in other domains," said Savoy. "You can get the most advanced technology available – the fastest car, the smartest cell phone – but if it is not useful or if usability fails, users should not be forced to change their approach or work. The technology should be redesigned.

"Similarly," she said, "EHRs should be redesigned to improve situational awareness for busy primary care physicians and support their tasks, including reviewing patient information, care coordination, and shared decision-making."