[This is the first in a series by Continuum, about how design can improve our healthcare system.--Ed.] Fixing our floundering healthcare system may be the single most complex design challenge ever. Bad design forced Dr. Bruce Mason*, the clinical director of a large outpatient department at one of the preeminent teaching hospitals in the country, to force out one of the best doctors in his department. The doctor who was let go, Dr. Davis, didn’t violate the doctor’s code of ethics. He wasn’t old enough to retire. He hadn’t been sued for malpractice. In fact, he was a renowned practitioner. Ultimately, Dr. Davis failed because he was unable to produce the required levels of documentation in the hospital’s version of an Electronic Health Record (EHR). “When one of my most senior clinicians had to stop seeing patients at this institution because he could not adapt to the switch from paper to electronic documentation, that was a troubling moment for me,” says Dr. Mason.
This may be the single, most complex design challenge ever.And if you’re thinking that Dr. Davis or the hospital should have just hired an assistant to transcribe his notes into electronic format, it wasn’t an option: Legally, Dr. Davis himself had to input the notes.
The Importance of Electronic Health RecordsThe United States has made a firm commitment to adopting EHRs, and utilizing them as one of the underpinnings of our future healthcare system. There will be hefty fines for hospitals and practitioners who do not adopt “meaningful use” of these systems by 2014. Supporters of EHRs predict a rosy future of increased efficiency, reduced error, improved coordination of care between providers, and a treasure mine of secure data for researchers. Detractors are armed with statistics about how hard it has been to get physicians to use EHRs, how much it costs to train them, and even instances where EHR implementations have been correlated with decreased efficiency and increased errors. In the end, EHRs can play a critical role in fixing our floundering healthcare system. But they will only be the panacea they are meant to be if they are designed with the full complexity of American healthcare in mind. We’re not going to right the ship simply by making any old electronic medical record. We’re going to have to make a really good one.
A Clerical WeaknessTo illustrate why redesigning the EHR system is such a hard problem, let’s go back to Dr. Mason and Dr. Davis. In the 1990s, the hospital began building an EHR system. The primary goal of the system was to document data from patient visits for billing and quality of care purposes. In addition, providers could share data with other clinicians across a larger healthcare system to facilitate communication and ensure continuity of care.
His handwriting drove Dr. Davis into forced retirement.Using the EHR as such became mandatory for Dr. Mason’s department in 2005, which was a reasonable request. Medical students have always been trained to take copious notes--long before the advent of digital records. In fact, note-taking was one of Dr Davis’s strengths. He was known to take detailed notes during a session and summarize them in an official paper medical record entry. However, those notes never made it into the EHR. If he had typed the notes into the digital EHR system, he would have spent almost a dozen hours a week sitting in front of a computer mindlessly transcribing his own work instead of practicing medicine. To be clear, Dr. Mason didn’t want Dr. Davis to stop practicing, but routine external audits exposed his chronic documentation deficiency to the point that sanctions were mandatory. One reason why the EHR system was so important was insurance--according to insurance, when there was a missing or incomplete note for a visit, it meant there was no visit, and therefore should not be reimbursed. Given the number of missing notes attributed to Dr. Davis, the financial repercussions would have been severe, if he continued working at the hospital. Dr. Mason did not want to move Dr. Davis into early retirement, but he had no choice. You may be thinking that Dr. Davis should have gotten with the times or that he shouldn’t have put his supervisor in that position. Or perhaps that when technology threatens to make your skills obsolete, you have to keep up.
Good isn’t Good EnoughBut Dr. Davis’ skills were not obsolete. He was as skilled a doctor on the day he had his last appointment as he ever was. However, he was not a strong enough typist to take full-scale electronic notes in session, and he lacked the time and the confidence with computers to get it done later. We just can’t afford to alienate our top talent, especially for clerical weaknesses.
A frightening pattern is emerging in efforts to fix healthcare.Ultimately, what forced Dr. Mason’s hand in firing Dr. Davis was a failure of design. At the same time, it isn’t accurate to say that the designers of the EHR failed, per se. They were tasked with creating a system that allowed for meticulous documentation of medical care in a digital format. Those designers did what they were asked, and they did a good job. But the relationships between people and systems in modern healthcare are sufficiently complex that good is no longer good enough. While Dr. Davis’ story is very unfortunate, it’s not uncommon. In fact, there’s a frightening pattern that’s beginning to emerge in efforts to redesign our healthcare system:
1. A person or group within the healthcare system is tasked with solving a problem. 2. They solve it--and solve it well--and it is implemented.But…
3. Unintended negative consequences of that solution show up somewhere else in the system in unanticipated ways.
Designing DownstreamSo, how do we get out in front of these issues when looking at redesigning our healthcare system? It will require grappling with the tough issues up front, rather than reacting to the disasters they create later on. It will require relaxing our rush to get it done, and taking up a more thoughtful approach to get it done right. It requires addressing the technical complexity, stakeholder complexity, information complexity, psychological complexity, and regulatory complexity at the same time. Most importantly, it will require policy makers, designers, engineers, doctors, and scores of others--who are all working on fixing healthcare separately--to work on developing a solution together.
Imagine if they had asked, “Who does the system touch?"Imagine that while the team from Dr. Mason’s hospital was still in the design phase of the EHR, they had followed their design downstream. If, during their research, they had asked, “Who does the EHR touch? Who has to directly interact with it? Whose life does it change, even if they never see it or hear of it? Whose way is it going to obstruct?” Those are hard things to predict, but you can take some of the guesswork out by making a serious investment in up-front design research. Instead of only doing customer research or user research, talk to as many of the stakeholders as you possibly can. It’s easy to say that we should talk to doctors, nurses, medical students, and researchers to help us build our system. But it’s much more nuanced than that. After all, no two doctors are alike--some are old, some are young; some are surgeons, some are psychiatrists. There are a lot of people to please, as well. Sometimes, of course, pleasing one group means making trade-offs that sting others. But hiding from that reality isn’t going to fix anything. Better to get the downstream stakeholders involved in the design process early and solicit input often. Heck, give them a whiteboard and a marker and let them sketch and help author requirements. Sounds like a lot of work, right? Well, it is. But taking a more holistic and human-centered approach to healthcare design will serve as an insurance policy against much larger amounts of re-work that our current trajectory is sure to produce. If we don’t change how we design systems for healthcare, Dr. Davis won’t be the last accidental casualty of good work and good intentions. There will be enough wounded soldiers in the battle for healthcare reform. We don’t need more friendly fire. *Names changed to protect privacy.