Sunday, July 17, 2011

Seeing Promise and Peril in Digital Records By Steve Lohr

 Technical standards may seem arcane, but they are often powerful tools of economic development and social welfare. They can be essential building blocks for innovation and new industries. The basic software standards for the Web are striking proof.

                                                             Photo illustration by The New York Times

 Safety is also a potent argument for standards. History abounds with telling examples, like the Baltimore fire of 1904. That inferno blazed for 30 hours, destroying more than 1,500 buildings across 70 city blocks. Fire engines from other cities came to help, but could not. Their hose couplings — each a different size — did not fit the Baltimore fire hydrants. Until then, cities saw little reason to adopt a standard size coupling, and local equipment manufacturers did not want competition. So competing interests undermined the usefulness of, and investment in, the technology of the day.
 Today, the matter of standards for electronic health records is raising similar concerns, prompting heated debate in recent meetings of representatives from medicine, industry, academia and government. The stakes, they say, could scarcely be higher. They agree that, when well designed and wisely used, digital records can deliver the power of better information to medicine, improving care and curbing costs. But computer forms, they add, can also be difficult to use, cluttered and distracting, causing more harm than good in health care.
 “This is an issue that potentially affects the health and safety of every American,” says Ben Shneiderman, a computer scientist at the University of Maryland.
 The controversy points to the delicate balancing of interests involved when creating technical standards that inherently limit some design choices yet try to keep the door open to innovation. It also raises the question of the appropriate role for government in devising such technology requirements.
 At issue is the Obama administration’s plan to develop standards to measure how effective and easy digital patient records are to use — applying a research discipline known as human-computer interaction or human factors. (The International Organization for Standardization, which is based in Geneva, defines the usability of a product by three attributes: “effectiveness, efficiency and satisfaction.”)
 The need to improve the usability of computerized records is clearly evident — and has been for some time. A 2009 study by the National Research Council, an arm of the National Academy of Sciences, found that electronic health record systems were often poorly designed, and so could “increase the chance of error, add to rather than reduce work flow, and compound the frustrations doing the required tasks.”
 At a government-sponsored gathering last month, Dr. David Brick, a pediatric cardiologist in New York, demonstrated how it took eight mouse clicks on a digital record to find the patient information presented comfortably on the single sheet of a paper chart. Hearing such complaints, countless times, from doctors and nurses is what prompted the administration to put usability on its policy agenda.
 The main users of electronic health records are doctors and nurses. And the uses are tasks like recording a patient’s basic information, ordering lab tests, electronically prescribing medications and checking for possibly dangerous drug interactions. For example, taking the blood thinner warfarin (Coumadin) with aspirin, which also inhibits clotting, increases the risk of internal bleeding. The most important early measurement, officials say, will be to ensure that the electronic records are designed to avoid errors, embracing the physician’s dictum, “First, do no harm.”
 The administration’s initiative takes on particular significance because this year is when the government begins spending billions of dollars to accelerate the adoption of computerized patient records.
 The incentive payments, typically as much as $44,000 a physician, begin this year. But those payments require doctors to make “meaningful use” of “certified” electronic health records. The payments are staggered over five years, and to get the money physicians must use the technology for increasingly extensive record-keeping and reporting. The administration has not said whether a usability standard will be in the next stage of requirements, due by early next year.
 The government says it is committed to working with technology companies, medical professionals and academics, to adopt the best approach. Yet common ground has been elusive so far.
 At a meeting last month at the National Institute of Standards and Technology in Gaithersburg, Md., Janet Campbell, a software developer at Epic Systems, a supplier of electronic health records, expressed the industry’s concerns. Doctors are discriminating consumers, she said, and companies like hers work on improving their products in the marketplace every day.
 “What’s taken as fact is that the industry has failed,” Ms. Campbell told the audience of health specialists and government officials. “I’m here to challenge that assumption.”
 She added, “I don’t believe that introducing government into this will produce better outcomes.”
 Mary Kate Foley, vice president of the user experience at Athenahealth, a health technology company, expressed similar sentiments at the meeting last month.
 Later, she explained that she thought the government should confine its efforts to analyzing the methods companies deploy to improve usability, like field studies in doctors’ offices. It should monitor and promote industry “best practices,” she recommended, but not do comparative measurements of different health record vendors or product features.
 “What scares me is design details mandated from on high,” Ms. Foley said. “That’s going to prevent me from making my electronic health records more usable. It will hurt innovation.”
 The administration’s health technology officials say they have no intention of dictating what electronic health records should look like, and they say the industry’s worries are overstated. “If we standardize the right things, we can promote innovation rather than stifle it,” says Dr. Douglas Fridsma, director of health information technology standards in the Department of Health and Human Services.
 The industry’s stance, some health and computer professionals say, understates the progress made in human factors and human-computer interaction research over decades. They cringed at the summary of a hearing held by a government advisory group in April, which began: “Usability is in the eyes of the beholder.”
 THERE is, to be sure, an element of art to designing the look and feel of computing objects that intuitively please users. Consider the iPad.
 But software design specialists point to ample research showing, for example, that changing the size, color and placement of graphic icons on a screen can reduce the time it takes to perform computing tasks. Searching from one digital page after another, they say, devours time and increases the chance of user errors. Each click to another screen to find information is another cognitive excursion, a tax on the brain.
 Doctors and nurses, specialists say, work in complex decision-making settings. But a lot of research, they note, has been done on how to improve human performance working in complex systems, including jet plane cockpits, air traffic control towers and nuclear power plant controls. Some of that expertise, they say, can surely be applied to doctors’ offices and hospitals.
 “There is no doubt about this being measurable and a science,” says Lana Lowry, who leads the human factors project for health information technology at the National Institute of Standards and Technology. (The institute, a federal agency, is working on usability measurements for the administration.)
 What is also beyond doubt is that the promise of digital records will be unfulfilled if doctors refuse to adopt them, because they regard the technology as cumbersome, time-consuming and possibly dangerous.
 “Usability is going to be the single greatest impediment to physician acceptance,” says Dr. Edward H. Shortliffe, a professor at the University of Texas Health Science Center in Houston.


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