1

ImprovingtheUserExperience

Thomas H Payne, MD, FACP, FACMI

Chair, AMIA Board of Directors

Medical Director, Information Technology ServicesUW Medicine

June24,2016AMDISPhysician-ComputerConnectionSymposium

Ojai,California

ImprovingtheUserExperienceUser ExperienceImproving

JAMA, June 20, 2012—Vol 307, No. 23

User experience

• What is the experience?

• Who is the user?

JAMA, June 20, 2012—Vol 307, No. 23

EHR distracts from personal connection

Entering data takes too long

Patient has limited involvement

Patient’s perspectiveMD Communication

% Yes, Definitely to did the doctor explain things in a way that was easy to understand, listen carefully to you, give you easy to understand

instructions about taking care of health problems/concerns, seem to know the important information about your medical history, show respect for

what you had to say, spend enough time with you

10 Murray E, Davis H, Tai SS, Coulter A, Gray A, Haines A. Randomisedcontrolled trial of an interactive multimedia decision aid on benign pros-tatic hypertrophy in primary care. BMJ 2001;323:493-6.

11 Murray E, Davis H, Tai SS, Coulter A, Gray A, Haines A. Randomisedcontrolled trial of an interactive multimedia decision aid on hormonereplacement therapy in primary care. BMJ 2001;323:490-3.

12 Fisher B, Britten N. Patient access to records: expectations of hospitaldoctors and experiences of cancer patients. Br J Gen Pract 1993;43:52-6.

13 Elbourne D, Richardson M, Chalmers I, Waterhouse I, Holt E. The New-bury maternity care study: a randomized trial to assess a policy of womenholding their own obstetric records. Br J Obstet Gynaecol 1987;94:612-9.

14 Draper J, Field S, Thomas H, Hare MJ. Should women carry theirantenatal records? BMJ 1986;292:603.

15 Pyper C, Amery J, Watson M, Crook C, Thomas B. Patients’ access to theironline electronic health records. J Telemed Telecare 2002;2:103-5.

16 Jones R, McConville J, Mason D, Macpherson L, Naven L, McEwen J. Atti-tudes towards, and utility of, an integrated medical-dental patient-heldrecord in primary care. Br J Gen Pract 1999;49:368-73.

17 Drury M, Yudkin P, Harcourt J, Fitzpatrick R, Jones L, Alcock C, MintonM. Patients with cancer holding their own records: a randomised control-led trial. Br J Gen Pract 2000;50:105-10.

18 Williams JG, Cheung WY, Chetwynd N, Cohen DR, El-Sharkawi S, FinlayI, et al. Pragmatic randomized trial to evaluate the use of patient-heldrecords for the continuing care of patients with cancer. Qual Health Care2001;10:159-65.

19 Warner JP, King M, Blizard R, McClenahan Z. Tang S. Patient-held sharedcare records for individuals with mental illness. Randomised controlledevaluation. Br J Psychiatry 2000;177:319-24.

20 Homer CS, Davis GK, Everitt LS. The introduction of a woman-heldrecord into a hospital antenatal clinic: the bring your own records study.Aust N Z J Obstet Gynaecol 1999;39:54-7.

21 Clauson J, Hsieh YC, Acharya S, Rademaker AW, Morrow M. Results ofthe Lynn Sage second-opinion program for local therapy in patients with

breast carcinoma: changes in management and determinants of wherecare is delivered. Cancer 2002;94:889-94.

22 Coblentz TR. Mills SE. Theodorescu D. Impact of second opinion patho-logy in the definitive management of patients with bladder carcinoma.Cancer 2001;91:1284-90.

23 Epstein JI. Walsh PC. Sanfilippo F. Clinical and cost impact ofsecond-opinion pathology. Review of prostate biopsies prior to radicalprostatectomy. Am J Surg Pathol 1996;20:851-7.

24 Graboys TB. Biegelsen B. Lampert S. Blatt CM. Lown B. Results of asecond-opinion trial among patients recommended for coronary angio-graphy JAMA 1992;268:2537-40.

25 Cyberdialogue and Deloitte Consulting. Taking the pulse: physicians andthe internet” to probe online healthcare use by physicians, perceptions ofpatient usage, and influence on physician practices.www.cyberdialogue.com/news/releases/2000/04-17-cch-docpatient.html (accessed 14 Jan 2002).

26 Borowitz SM, Wyatt JC. The origin, content, and workload of E-mail con-sultations. JAMA 1998;280:1321-4.

27 Balas EA, Jaffrey F, Kuperman GJ, Boren SA, Brown GD, Pinciroli F,Mitchell JA Electronic communication with patients. Evaluation ofdistance medicine technology. JAMA 1997;278:152-9.

28 Piette JD, Weinberger M, McPhee SJ. The effect of automated calls withtelephone nurse follow-up on patient-centered outcomes of diabetescare: a randomized, controlled trial. Med Care 2000;38:218-30.

29 Mandl KD, Kohane IS, Brandt AM. Electronic patient-physician commu-nication: problems and promise. Ann Intern Med 1998;129:495-500.

30 Bessell TL, McDonald S, Silagy CA, Anderson JN, Hiller JE, Sansom LN.Do Internet interventions cause more harm than good? A systematicreview. Health Expectations 2002;5:28-37.

31 Coulter A. Paternalism or partnership? Patients have grown up-andthere’s no going back. BMJ 1999;319:719-20.

32 Gray M. The resourceful patient. www.resourcefulpatient.org/ (accessed 8April 2003).

What patients want from their doctors

Patients want many things from their doctors, not all of which arepossible. Below, however, is a list of things that patients seem towant from their doctor and which should be possible.+ Eye contact—There is nothing worse than walking into aconsulting room and not getting any eye contact from the doctor.It happened to me only last week; I knocked on the door, to begreeted with “Come” and to find the doctor sitting looking at hiscomputer screen. He continued to do so while asking why I hadcome to see him.+ Partnership—Patients want to be people who doctors do thingswith, not people that doctors do things to. Patients want to beconsulted about their condition, their treatment, and how thingswill progress from the consultation.+ Communication—Communication from doctor to patient andvice versa is the key to a successful consultation. Many patientsstill feel that they are entering “alien territory” when they go tosee their doctor. In many cases they are scared, they don’tunderstand what the doctor is saying, and they are not able totake everything in that they are told. Just as doctors may have

trouble understanding a patient’s explanation of symptoms, sopatients may have trouble understanding a doctor’s explanationof the diagnosis.+ Time—Patients want to spend more time with their doctor:they want time to be able to explain things and have thingsexplained to them. We all know that there is a shortage ofdoctors, and we know that a doctor’s time is valuable. However, ifone wish could be granted for patients it would be for more timewith their doctor.+ Appointments—Patients want to get to see their doctor within areasonable time; not weeks, but rather a few days, or, in the caseof a person who is unwell, a few hours if possible.

These are just five wishes that we are told on a daily basis bypatients. The relationship between a doctor and a patient is special,and one that works well in most cases. It is also a partnership, apartnership that should be valued by doctor and patient.

Mike Stone director, Patients Association, Harrow

Good patient

page 3 of 3BMJ VOLUME 326 14 JUNE 2003 bmj.com

10 Murray E, Davis H, Tai SS, Coulter A, Gray A, Haines A. Randomisedcontrolled trial of an interactive multimedia decision aid on benign pros-tatic hypertrophy in primary care. BMJ 2001;323:493-6.

11 Murray E, Davis H, Tai SS, Coulter A, Gray A, Haines A. Randomisedcontrolled trial of an interactive multimedia decision aid on hormonereplacement therapy in primary care. BMJ 2001;323:490-3.

12 Fisher B, Britten N. Patient access to records: expectations of hospitaldoctors and experiences of cancer patients. Br J Gen Pract 1993;43:52-6.

13 Elbourne D, Richardson M, Chalmers I, Waterhouse I, Holt E. The New-bury maternity care study: a randomized trial to assess a policy of womenholding their own obstetric records. Br J Obstet Gynaecol 1987;94:612-9.

14 Draper J, Field S, Thomas H, Hare MJ. Should women carry theirantenatal records? BMJ 1986;292:603.

15 Pyper C, Amery J, Watson M, Crook C, Thomas B. Patients’ access to theironline electronic health records. J Telemed Telecare 2002;2:103-5.

16 Jones R, McConville J, Mason D, Macpherson L, Naven L, McEwen J. Atti-tudes towards, and utility of, an integrated medical-dental patient-heldrecord in primary care. Br J Gen Pract 1999;49:368-73.

17 Drury M, Yudkin P, Harcourt J, Fitzpatrick R, Jones L, Alcock C, MintonM. Patients with cancer holding their own records: a randomised control-led trial. Br J Gen Pract 2000;50:105-10.

18 Williams JG, Cheung WY, Chetwynd N, Cohen DR, El-Sharkawi S, FinlayI, et al. Pragmatic randomized trial to evaluate the use of patient-heldrecords for the continuing care of patients with cancer. Qual Health Care2001;10:159-65.

19 Warner JP, King M, Blizard R, McClenahan Z. Tang S. Patient-held sharedcare records for individuals with mental illness. Randomised controlledevaluation. Br J Psychiatry 2000;177:319-24.

20 Homer CS, Davis GK, Everitt LS. The introduction of a woman-heldrecord into a hospital antenatal clinic: the bring your own records study.Aust N Z J Obstet Gynaecol 1999;39:54-7.

21 Clauson J, Hsieh YC, Acharya S, Rademaker AW, Morrow M. Results ofthe Lynn Sage second-opinion program for local therapy in patients with

breast carcinoma: changes in management and determinants of wherecare is delivered. Cancer 2002;94:889-94.

22 Coblentz TR. Mills SE. Theodorescu D. Impact of second opinion patho-logy in the definitive management of patients with bladder carcinoma.Cancer 2001;91:1284-90.

23 Epstein JI. Walsh PC. Sanfilippo F. Clinical and cost impact ofsecond-opinion pathology. Review of prostate biopsies prior to radicalprostatectomy. Am J Surg Pathol 1996;20:851-7.

24 Graboys TB. Biegelsen B. Lampert S. Blatt CM. Lown B. Results of asecond-opinion trial among patients recommended for coronary angio-graphy JAMA 1992;268:2537-40.

25 Cyberdialogue and Deloitte Consulting. Taking the pulse: physicians andthe internet” to probe online healthcare use by physicians, perceptions ofpatient usage, and influence on physician practices.www.cyberdialogue.com/news/releases/2000/04-17-cch-docpatient.html (accessed 14 Jan 2002).

26 Borowitz SM, Wyatt JC. The origin, content, and workload of E-mail con-sultations. JAMA 1998;280:1321-4.

27 Balas EA, Jaffrey F, Kuperman GJ, Boren SA, Brown GD, Pinciroli F,Mitchell JA Electronic communication with patients. Evaluation ofdistance medicine technology. JAMA 1997;278:152-9.

28 Piette JD, Weinberger M, McPhee SJ. The effect of automated calls withtelephone nurse follow-up on patient-centered outcomes of diabetescare: a randomized, controlled trial. Med Care 2000;38:218-30.

29 Mandl KD, Kohane IS, Brandt AM. Electronic patient-physician commu-nication: problems and promise. Ann Intern Med 1998;129:495-500.

30 Bessell TL, McDonald S, Silagy CA, Anderson JN, Hiller JE, Sansom LN.Do Internet interventions cause more harm than good? A systematicreview. Health Expectations 2002;5:28-37.

31 Coulter A. Paternalism or partnership? Patients have grown up-andthere’s no going back. BMJ 1999;319:719-20.

32 Gray M. The resourceful patient. www.resourcefulpatient.org/ (accessed 8April 2003).

What patients want from their doctors

Patients want many things from their doctors, not all of which arepossible. Below, however, is a list of things that patients seem towant from their doctor and which should be possible.+ Eye contact—There is nothing worse than walking into aconsulting room and not getting any eye contact from the doctor.It happened to me only last week; I knocked on the door, to begreeted with “Come” and to find the doctor sitting looking at hiscomputer screen. He continued to do so while asking why I hadcome to see him.+ Partnership—Patients want to be people who doctors do thingswith, not people that doctors do things to. Patients want to beconsulted about their condition, their treatment, and how thingswill progress from the consultation.+ Communication—Communication from doctor to patient andvice versa is the key to a successful consultation. Many patientsstill feel that they are entering “alien territory” when they go tosee their doctor. In many cases they are scared, they don’tunderstand what the doctor is saying, and they are not able totake everything in that they are told. Just as doctors may have

trouble understanding a patient’s explanation of symptoms, sopatients may have trouble understanding a doctor’s explanationof the diagnosis.+ Time—Patients want to spend more time with their doctor:they want time to be able to explain things and have thingsexplained to them. We all know that there is a shortage ofdoctors, and we know that a doctor’s time is valuable. However, ifone wish could be granted for patients it would be for more timewith their doctor.+ Appointments—Patients want to get to see their doctor within areasonable time; not weeks, but rather a few days, or, in the caseof a person who is unwell, a few hours if possible.

These are just five wishes that we are told on a daily basis bypatients. The relationship between a doctor and a patient is special,and one that works well in most cases. It is also a partnership, apartnership that should be valued by doctor and patient.

Mike Stone director, Patients Association, Harrow

Good patient

page 3 of 3BMJ VOLUME 326 14 JUNE 2003 bmj.com

BMJ VOLUME 326 14 JUNE 2003

The physician experience

Do EHRs help us be better doctors?

• Physician job satisfaction declining

• Many reasons—EHRs are one

• “These physicians are concentrating not only on the patient but on typing the history, checking boxes, performing order entry, and other electronic tasks.”

Texting While Doctoring: A Patient Safety HazardChristine A. Sinsky, MD, and John W. Beasley, MD

Texting while driving is associated with a 23-fold in-creased risk for crashing (1) and is illegal in most states

(2). Using a cell phone while driving reduces the amountof brain activity devoted to driving by 37% (3). Multitask-ing is dangerous—cognitive scientists have shown that en-gaging in a secondary task disrupts primary task perfor-mance (3).

Might physician typing into electronic health recordspose similar risks? As when driving, physicians also need tobe alert to environmental cues and unexpected turns. Multi-tasking can undermine the core activities of observation,communication, problem solving, and developing trustingrelationships. Although it can be argued that texting isunrelated to the task of driving and that typing may be partof the patient care process, we believe the issue of distrac-tion is nonetheless relevant, especially given the realities ofinformation chaos during the encounter (4). Problems incare have been documented (5).

Although there is a relative lack of observational data,in clinics across the country we have observed patients sendsignals of depression, disagreement, and lack of under-standing and have witnessed kind, compassionate, andwell-intended physicians missing these signals while theymultitask. These physicians are concentrating not only onthe patient but on typing the history, checking boxes, per-forming order entry, and other electronic tasks (6). Onephysician noted, “I am always multitasking . . . I am enter-ing orders, checking labs, downloading information while Italk to the patient. It requires chronic hypervigilance,which is exhausting and demands conscious effort to stayin the ‘present’ with the patient” (Day S. Personal commu-nication.). External forces drive this. Vendors market theirelectronic health records with the pitch that costs will beoffset by a reduction in transcription expenses as physicianstype their notes. Computerized physician order entry dis-places to the physician clerical tasks once performed byothers, increasing time commitment and cognitive inter-ruptions (7).

Stage 2 meaningful use criteria (8) require clinicians totype in orders so that physicians view clinical decision-support reminders; however, most tests ordered in the pri-mary care setting do not require nor can they be addressedby this system. We found that less than 0.1% of the testsordered in our practice could potentially benefit frompoint-of-care clinical decision support, a function not yetavailable for these tests. We are concerned about the haz-ards of applying a work burden to 100% of orders whenless than 0.1% might benefit.

Time motion studies in our practice demonstrate thatan additional 3 hours per week of physician time is lost to

order entry when physicians, rather than staff, performthese tasks. The time cost of this additional clerical workprevents physicians from “working to the top of their li-cense,” is a form of waste, and effectively reduces primarycare capacity. Yet, this workflow is associated with penal-ties in stage 2 meaningful use reporting.

It is time to envision technologically supported, team-based models of care within a more sophisticated socio-technical framework. In these models, physicians give theirpatients undivided attention while other team membersperform clerical and routine clinical functions, such as dataacquisition, visit note documentation, and order entry.

Emerging innovative models hold promise. We haveobserved in other practices (6, 9) and developed our owncollaborative care model in which nurses, medical assis-tants, or health coaches manage electronic information,thus allowing the physician to provide undivided attentionto the patient. Practices using these new models reportgreater patient access, better staff and physician satisfac-tion, and higher-quality metrics.

To flourish, these new models need both new policiesand new technologies, such as a team login to allow seam-less collaborative documentation between nurse and physi-cian, team signatures to empower nursing staff to sign offon much of the paperwork in the practice, and meaningfuluse policies that allow nonclinical staff to fully supportcare.

New payment models will also help. The current visit-based, fee-for-service model contributes to the pressures to“text while doctoring” as clinicians record history on bill-ing templates, progress through drop-down boxes to justifya level of service, distractedly multitask, and thus give theirpatients only partial attention. In contrast, we visited apractice under a global payment model in which clinicianrevenue does not depend on recording the encounter in avisit-based, level-of-service framework. Documentation inthis practice, done largely by health coaches, focuses on thelongitudinal portions of the record (problem list, patientgoals, social history, and medication history), that is, thoseportions of the record that are most useful for care coordi-nation and long-term management.

A tsunami is approaching the U.S. health care system:an obese, aging population, many newly insured, and adelivery system with limited primary care capacity, lownumbers of students choosing primary care, and increasingburnout. But the problem is not simply one of physiciansupply—it is also one of physician utilization, which couldbe at least partially addressed by changing how work isorganized, tasks are distributed, and the enterprise is regu-lated. At a time when so many are calling for teamwork inhealth care (10), policies and technologies that support

Annals of Internal MedicineIdeas and Opinions

782 © 2013 American College of Physicians

Downloaded From: http://annals.org/ by a Oregon Health Sciences University User on 01/13/2014

Ann Intern Med. 2013;159:782-783.

Enhancing patient safety and quality of care byimproving the usability of electronic health recordsystems: recommendations from AMIABlackford Middleton,1 Meryl Bloomrosen,2 Mark A Dente,3 Bill Hashmat,4

Ross Koppel,5 J Marc Overhage,6 Thomas H Payne,7 S Trent Rosenbloom,8

Charlotte Weaver,9 Jiajie Zhang10

1Clinical Informatics Researchand Development, PartnersHealthCare System, HarvardMedical School, Wellesley,Massachusetts, USA2AMIA, Bethesda, Maryland,USA3GE Healthcare IT, Boston,Massachusetts, USA4CureMD, New York,New York, USA5Department of Sociology,University of Pennsylvania,Philadelphia, Pennsylvania,USA6Siemens Health Services (HS)Business Unit, Malvern,Pennsylvania, USA7Information TechnologyServices, UW Medicine, Seattle,Washington, USA8Department of BiomedicalInformatics, VanderbiltUniversity Medical Center,Nashville, Tennessee, USA9School of BiomedicalInformatics, Gentiva HealthServices, Atlanta, Georgia, USA10University of Texas HealthScience Center at Houston,Houston, Texas, USA

Correspondence toDr Blackford Middleton,Partners HealthCare System,93 Worcester Street, Wellesley,MA 02481, USA;bmiddleton1@partners.org

To cite: Middleton B,Bloomrosen M, Dente MA,et al. J Am Med InformAssoc Published Online First:[please include Day MonthYear] doi:10.1136/amiajnl-2012-001458

ABSTRACTIn response to mounting evidence that use of electronicmedical record systems may cause unintendedconsequences, and even patient harm, the AMIA Boardof Directors convened a Task Force on Usability toexamine evidence from the literature and makerecommendations. This task force was composed ofrepresentatives from both academic settings and vendorsof electronic health record (EHR) systems. After a carefulreview of the literature and of vendor experiences withEHR design and implementation, the task forcedeveloped 10 recommendations in four areas: (1) humanfactors health information technology (IT) research, (2)health IT policy, (3) industry recommendations, and (4)recommendations for the clinician end-user of EHRsoftware. These AMIA recommendations are intended tostimulate informed debate, provide a plan to increaseunderstanding of the impact of usability on the effectiveuse of health IT, and lead to safer and higher quality carewith the adoption of useful and usable EHR systems.

INTRODUCTIONUS healthcare delivery is in the midst of a profoundtransformation which results, at least in part, fromFederal public policy efforts to encourage the adop-tion and use of health information technology(health IT). For example, HITECH regulations1

within the American Recovery and ReinvestmentAct2 incentivize health IT use,3 4 and are changingthe practice of medicine and clinical care delivery inboth beneficial3 5 6 and untoward ways.7 Increasedadoption of electronic health record (EHR) systemshas been accompanied by heightened recognition ofissues related to ‘goodness of fit’ in the user-friendliness of EHR systems.8 Some EHR userslament that health IT seems designed more for clin-ical transactions than for clinical care, and may notbe easy to use in some care settings.9 10 In addition,many EHR systems require extensive training andlack standard user interfaces so that clinicians whowork in multiple care settings using disparate tech-nologies may struggle with the differences in interfacedesign, with adverse impact on patient safety.11 Userinterface design can influence provider productivity:well-designed interfaces speed work, while poorlydesigned interfaces steal minutes from busy sche-dules. The Institute of Medicine (IOM) report,Health IT and Patient Safety: Building Safer Systemsfor Better Care identified means by which health ITcan lead to safer care, as well as introduce new safety

risks. A critical component of safe and effective useof health IT is usability—‘the effectiveness, efficiency,and satisfaction with which the intended users canachieve their tasks in the intended context of productuse.’12 The IOM recommended that ‘[t]he Secretaryof HHS [Health and Human Services] should specifythe quality and risk management process require-ments that health IT vendors must adopt, with a par-ticular focus on human factors, safety culture, andusability’ (recommendation 6, p 99).

PURPOSE OF THIS AMIA STATEMENTGiven the anticipated adoption of health IT, andthe potential for increased health IT-related harmor potential error, the AMIA Board of Directorsconvened a task force of members drawn from aca-demia, clinical practice, and industry to produce aset of AMIA recommendations on enhancingpatient safety and the quality of care with improvedusability of EHR systems. These AMIA recommen-dations are intended to stimulate informed debate,form the basis of a plan to increase understandingof the impact of usability on the effective use ofhealth IT, and lead to safer and higher quality carewith the adoption of useful and usable EHRsystems.To address this issue, the task force convened for

over a year. Subcommittees reviewed the literatureon usability in health IT, current related activitiesunderway at various US Federal agencies, lessonslearned regarding usability and human factorsin other industries, and current federally fundedresearch activities. The key principles and recom-mendations described below are based on thesereviews.

RELATIONSHIP OF USABILITY TO OPTIMALHEALTHCARE PRACTICETo frame this discussion, the AMIA Task Force onUsability considered the following issues related tohealth IT: (1) safe and effective use of EHR, (2) EHRusability, and (3) EHR usability-associated medicalerrors. Recent reports describe the safe and effectiveuse of EHR as a property resulting from the carefulintegration of multiple factors in a broad socio-technical framework,13 including coordination andconsideration across requirements assessment, appli-cation design, usability and human factors engineer-ing, implementation, training, monitoring, andfeedback to application developers.1 14–16 Followingbest practices for EHR implementation is essential to

Middleton B, et al. J Am Med Inform Assoc 2013;0:1–7. doi:10.1136/amiajnl-2012-001458 1

AMIA Board Position Paper

Copyright 2013 by American Medical Informatics Association.

group.bmj.com on January 25, 2013 - Published by jamia.bmj.comDownloaded from

AMIA’s position on usability

• 2013 task force of ten people: users, vendors, academics

• Usability key to safety

• Recommendations directed at policy, end-users, and research

Publ

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ates

Green = drug-allergy, blue = drug-drug

The experience of decision support

“How do we ensure the EHR helps us when we need it and stands out of the way when we don’t?"

Anonymous reviewer

Design is difficult and important

• Current EHR designs are the product of methods we have used for decades

• Don’t ask (users what they want), observe them.

• Observe design in everyday life: Doors for example.

Basic Books ISBN-10: 0465050654

What does need for scribe tell us about user experience?

• Popular with many physicians

• Google “CRICO youtube EHR”

Improving the experience

EHR2020TaskForceRecommendations

Fulltextavailableathttp://jamia.org

Report of the AMIA EHR 2020 Task Force onthe Status and Future Direction of EHRs

Thomas H. Payne,1 Sarah Corley,2 Theresa A. Cullen,3 Tejal K. Gandhi,4

Linda Harrington,5 Gilad J. Kuperman,6 John E. Mattison,7 David P. McCallie,8

Clement J. McDonald,9 Paul C. Tang,10 William M. Tierney,11 Charlotte Weaver,12

Charlene R. Weir,13 Michael H. Zaroukian14

....................................................................................................................................................

Over the last 5 years, stimulated by the changing healthcareenvironment and the HITECH Meaningful Use (MU) EHRIncentive program, EHR adoption has grown remarkably, andthere is early evidence of benefits in safety and quality as aresult.1,2 However, with this broad adoption many cliniciansare voicing concerns that EHR use has had unintended clinicalconsequences, including reduced time for patient-clinician in-teraction,3 transferred new and burdensome data entry tasksto front-line clinicians,4,5 and lengthened workdays.6,7,8

Interoperability between different EHR systems has languisheddespite large efforts.9,10 These frustrations are contributingto a decreased satisfaction with professional work life.11,12,13

In professional journals,14 press reports,15,16,17 on wards andin clinics, we have heard of the difficulties that the transition toEHRs has created.18 Clinicians ask for help getting throughtheir days, which often extend into evenings devoted to writingnotes. Examples of comments include “Computers alwaysmake things faster and cheaper. Not this time.” and “My doctorpays more attention to the computer than to me.”

Ultimately, our goal is to create a robust, integrated, inter-operable health system that includes patients, physician prac-tices, public health and population management, and supportfor clinical and basic sciences research. EHRs are an importantpart of this ecosystem, along with many other clinical systems,but future ways in which information is transformed into knowl-edge will likely require all parts of the ecosystem working to-gether. This ecosystem has been referred to as the “learninghealth system.”19 Potentially every patient encounter could pre-sent an opportunity for patients and clinicians alike to contrib-ute to our understanding of health care and participate inresearch and clinical trials.

As part of the learning health system, EHRs have long beentouted as beneficial to the safety and quality of health care, andstudies have shown potential benefits related to information ac-cessibility, decision support, medication safety, test resultmanagement, and many other areas.20,21 However, implemen-tation of any new technology leads to new risks and unintendedconsequences; these too have been well documented.22,23,24

Much of the focus of the last decade, via MU and other in-centives, was to encourage providers and other health profes-sionals to implement EHRs and use them to capture and sharedata important to quality and cost. The work now ahead is toensure that these systems are designed and implemented in away that yields promised benefits to efficiency, quality andsafety with fewer side effects.25 While cost, usability, and otherconsiderations are important, patient safety and quality of careneed to guide how we optimize these systems.

There can be a tension between efficiency and safety.Medication reconciliation is a good example—medication er-rors at transitions of care are a significant safety concern andrepresent a rationale for adding safeguards despite the impacton time and process.26 EHRs now include detailed processesto reconcile medications that some providers feel add to theirworkload and slow them down. Informed by careful stud-ies,27,28,29 tradeoffs do need to be made to strike the right bal-ance. However, there are many ways to optimize both safetyand efficiency and this is the goal of the recommendations ofthe AMIA EHR 2020 Taskforce.

As the professional home of health informatics profes-sionals, AMIA is well qualified to address many of the health ITchallenges from a wide range of perspectives. AMIA membersinclude informaticians, clinicians, scientists, vendors, innova-tion and implementation scientists, change agents, and peoplewho cross all these boundaries; our members develop, imple-ment and study ways to manage information for patients, forprofessionals in their clinical practices, for public health and forclinical research. Within EHR activities, AMIA members havedeveloped, implemented, studied, and refined EHRs, and advo-cated for their broader use for nearly 40 years. AMIA has re-cently addressed electronic documentation30 and usability31

because of the importance of these areas to EHR success. TheAMIA Board of Directors chartered the multidisciplinary EHR2020 Task Force to develop recommendations on how we canresolve the EHR issues that have been raised.

While EHRs are a critical part of the learning health system,this report focuses only on near-term strategies to address

Corresponding author: Thomas H Payne, MD, UW Medicine Information Technology Services, Box 359968, 325 Ninth Ave, Seattle, WA 98104-2499, USA,tpayne@u.washington.edu

VC The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved.For Permissions, please email: journals.permissions@oup.com

For numbered affiliations see end of article.

AMIA

POSITIONPAPER

1

Payne TH, et al. J Am Med Inform Assoc 2015;0:1–11. doi:10.1093/jamia/ocv066, AMIA Position Paper Journal of the American Medical Informatics Association Advance Access published May 28, 2015

Sarah Corley, MDCMO, NextGen

Theresa A. Cullen, MDCMIO, Veterans Health Administration

Tejal K. Gandhi, MD, MPHPresident, National Patient Safety Foundation

Linda Harrington, PhD, DNP, RN-BC, CNS, CPHQ, CENP, CPHIMS, FHIMSSVice  President and Chief Nursing Informatics Officer, Catholic Health Initiatives

Gilad J. Kuperman, MD, PhD, FACMIDirector, Interoperability Informatics, New York  Presbyterian Hospital

Ellen Makar, MSN, RN-BC, CCM, CPHIMSCENP Senior Policy Advisor Office of  Consumer eHealth, Office of the National Coordinator for Health IT, US Department of  Health and Human Services

John E. Mattison, MDAssistant Medical Director, CMIO, Kaiser Permanente

David P. McCallie, Jr., MDCerner Corporation

Clement J. McDonald, MD, FACMIDirector, National Institutes of Health, National  Library of Medicine

Paul C. Tang, MD, FACMIVP, Chief Innovation and Technology Officer Palo Alto  Medical Foundation

William M. Tierney, MD, FACMI, MACPPresident and CEO, Regenstrief Institute, Inc. 

Charlotte Weaver, RN, MSPH, PhD, FAANHealthcare Executive and Board Member

Charlene R. Weir, BS, PhD, RNAssociate Professor, Department of Biomedical Informatics, University of Utah

Michael H. Zaroukian, MD, PhDVice President & Chief Medical Information Officer,  Sparrow Health System

Task Force on Status and Future Direction of EHRs: EHR-2020 Task Force

Tom Payne, MD, FACMIMedical Director, UW Medicine ITS, University of  Washington, (Chair)

AMIAStaffExecutive–KarenGreenwoodOperational–PhyllisBurchmanCommunications–KristaMartin

EHR2020TaskForceRecommendations

1. Improvedocumentationrequirementsandfunctionalitytoempowerpatients

2. Refocusregulationssothatpatientsandtheircaregiverscanderivethemostbenefit

3. Increasetransparency4. Fosterinnovation

5. Supportperson-centeredcare

Full text available at http://jamia.org

Tenrecommendationsinfiveareas

NEED• Need to imagine and build next generation of EHRs• Public standards-based application programming interfaces (APIs) and data standards• Permit patients to gain access to their entire medical record• Investments in research on how best to capture and integrate data, and to design new

interfaces• To know how to better use data to change individual behavior and system change

HOW• EHR vendors should use pubic standards-based APIs (JASON Task Force

recommendations)• Standards should support ecosystems of innovation to emerge inside and outside

traditional health IT communities. • Research into how to use data to change provider and system behavior

Foster InnovationRecommendations 3, 8, 9, 10

Our brains are designed for speech

Graphic credit: Prof.Genevieve B. Orr http://www.willamette.edu/~gorr/classes/cs449/brain.html

auditory auditory association

Broca’s area

This project was supported by grant number R21HS023631 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.

“45 year old female with pulmonary sarcoidosis…”

Record note (~5 minutes)

Edit and sign note (~3 min)

PHYSICIAN TIME COMPUTER TIME

5 minutes

Transmission to server

Voice converted to text

Text formatted

Formatted note sent

to EHR Inbox

This project was supported by grant number R21HS023631 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.

We can and must improve the user experience.

Thank you!

www.amia.org

tpayne@u.washington.edu