Problems with Electronic Medical Records
Finding documented problems with EMRs is a challenge; no one wants to brag about their failures. However, a few prominent failures of medical systems are readily available, namely the physician rejection of the order entry system at Cedars Sinai and the struggles at Kaiser as they tried to implement an EMR system.
Cedars Sinai Medical Center in Los Angeles spent $34 million developing and deploying a physician order entry system for medications, labs, and procedures. Physicians found that it took much, much longer to use the new computer system than did the same ordering with pen and paper. With physicians already working 80 hours per week, there just wasn't the extra time available. Physicians also found that there were severe limitations on their ability to make medical judgments. To make matters worse, the system failed to recognize words with slight misspellings. And physicians daily faced a flood of excessive electronic reminders, questions, and alerts with the new system. Finally, several hundred physicians refused to use the system, and the administration was forced to cancel the implementation. All this occurred at one of the most wired hospitals in the nation (Connolly, 2005).
Not far away at Oakland-based Kaiser Health Plan, there were many problems with its implementation of the Clinical Information System (CIS), co-developed with IBM. A published study of Kaiser's experience at their Hawaii clinics revealed numerous problems. However, reduced clinician productivity was one of the key causes. More specifically, clinicians were taking an extra 30 to 75 minutes per day to do their work, because there were too many steps to complete simple tasks, and the system was too cumbersome to adapt to the needs of the clinicians. All these symptoms occurred after an initial learning period (Scott, Rundall, Vogt, & Hsu, 2005).
CIS was ultimately abandoned, and Kaiser is now implementing Epic's EMR. Unfortunately, there is yet more bad news from Kaiser; the Epic implementation is having difficulties (Rosencrance, 2006). It is possible that Kaiser's second attempt at an EMR implementation will also join the unfavorable statistics on EMR implementations, where failure rates are around 30% (Connolly, 2005).
What are the underlying causes of these problems? Some authors warn of excessive training costs with EMRs. Also, physicians are reluctant to use a system that takes more time to complete a task. "This is a result of EMRs that have been over-engineered and are not intuitive, forcing physicians to spend more time clicking through screens and menus to get their work done" (Brown, 2005, p. 47). Some clinics report that users often need between six and twelve months before they are comfortable using the new technology. Even after training, physicians are often less productive because the EMR slows them down (Tipirneni, 2006).
The physicians at Cedars Sinai faced excessive time on tasks and an overload of information. Kaiser physicians faced long training times and a loss of productivity. Other users on other EMRs had similar experiences. These problems are hallmarks of systems with usability problems, systems designed without the users at the center of the design process. Our own experience with physicians interacting with EMRs provides insights into the causes of these user challenges.