Simplicity driven EHRs

Kenton Kivestu

IHLST

May 19, 2010

Gardent, Conway, Zubikoff

EHRs: demand and simplicity

In 1998, the combined user base of Google, Facebook and Twitter was zero. Ten years later, the
three web services have one billion plus unique monthly users together. The staggering growth
was driven by a multitude of reasons; but the particular companies which prevailed – Google
rather than Yahoo, Facebook rather than MySpace – all have a common secret weapon:
simplicity. Their success has been not been driven by innovation alone but rather by providing
innovative, easy-to-use products that catch on quickly.

In the EHR ecosystem today, providers are cramming oodles of functionality into systems and
sacrificing usability. Strong demand for EHRs driven by federal stimulus money, payer
incentives and physician time constraints makes has created an attractive market. But providers
have yet to utilize the simplicity as a key tactic to unlocking market value.

This paper will discuss the importance of keeping simplicity at the center of the design
philosophy (citing examples from consumer technology) and recommendations for designing
simpler EHR systems.

The focus on simplicity is paramount because it speeds user adoption, serves to create uniform
standards and paves the way for future healthcare IT innovation that drives real value for all
stakeholders.

Simplicity is key to adoption

Today, the status quo in EHR systems for physicians is complicated, legacy systems that involve
expensive hardware installations and boast a jungle of features in a complicated user interface
(see exhibit 2).1 Athena Health and Ingenix have introduced web-based EHRs with more
affordable payment models and no hardware installations – but it’s not enough.5

John Maeda, a former MIT professor and now the Dean of the US’s preeminent design school
The Rhode Island School of Design, proposes two laws of simplicity which would greatly help
EHR providers:

1) Reduce: remove and hide features until only the core remains (offshoot of the Pareto
Principle which suggests 80% of benefit will come from 20% of features)7
2) Organize: make a system of many appear fewer6

Twitter is one example of a web service that saw success by reducing functionality to create a
more simple (and useful experience). Twitter took a common functionality – blogging – which
has many bells and whistles (long posts, inserting pictures, bolding text) and reduced it to its
core: a short message. The result was a simple product that had skyrocketing adoption.
Apple’s simple, easy-to-use products provide an example of Maeda’s second law: organize.
Below is a diagram which charts the evolution of the iPod controls, illustrating how the controls
started simple, became more complicated and then settled on the simplest solution.

The functionality of the three iPod wheels above is identical, yet the wheel on the far right is by
far the simplest way to expose the functionality. The difference between the middle wheel and
right wheel is superior organization of ideas and functionality – this has major implications for
EHRs.

Today’s EHRs today are unnecessarily over-complicated. They are grossly magnified versions of
the center wheel – but they don’t need to be. A comparison of core EHR functionality to general
Facebook functionality highlights the parity. For example, consider the images of a patient
profile on Ingenix and a user profile on Facebook:
Even at a cursory glance, there are striking differences between the two systems even though
they are both capable of storing the same information. The Facebook interface utilizes white
space, has less clickable options (15 vs. 50+ for Caretracker), embeds a picture (which could
help build patient familiarity) but most importantly layers information – allowing a user to see a
quick overview and then drill into specific areas with a mouse click to reveal more detail.
Facebook is nothing more than a reduced and organized Ingenix Caretracker.

The above example compares just one aspect of EHRs with facebook: the user profile. However,
for every EHR feature, Facebook has a simple equivalent, as shown in the table below.

Users are adopting Twitter, Apple products and Facebook in droves – Facebook alone is
expected to cross the 500 million user mark in June 2010.5 And this growth is fueled by people
aged 45 – 65, the same demographic that makes up a majority of US physicians.3 Yet only 5% of
small physician practices use EHRs.4 It is important to note that many significant trends are
driving Apple, Facebook and Twitter adoption but an undeniable common thread that all share is
simple, easy to use products.

Recommendations for building simplicity driven EHRs

Hire designers: to co-design systems with engineering teams.

Use organization ruthlessly: Facebook maintains an aura of simplicity due to organization.
Employ the same tactics. Most EHRs today show the same screen to a doc and an admin: the doc
doesn’t need to see the appointment scheduling and the admin doesn’t need to see the lab results.
A simpler user experience might simply start with one noting who they are.

Reduce and focus on core features: Twitter stripped blogging of almost all its functionality and
became popular as a result. Determine what the kernel of doctor’s needs are and remove any
functionality outside it.

Add white space, remove text: Facebook’s clean look comes from whitespace. It also helps users
find the information they’re seeking faster. It also addresses the dilution factor – the more links
there are, the less important each of them seem.

Move to shorter development cycles: Great systems are designed through iteration. Don’t spend
years developing a single system as Siemens has done; iterate in months or weeks and get doctor
feedback immediately.

Establish a better user feedback loop: Start a “trusted” doctors committee of eight or ten doctors
whom you can test new designs on and get instant feedback from.

Make “starting up” easy: Apple strives to design experiences (not just products) and is known to
take pains to design packaging. EHRs should simplify all aspects as well: eliminate upfront
installation fees. Charge customers a flat monthly fee to simplify billing.

Conclusions

The technology to build a simple HER exists. The demand for simple EHRs exists. Yet the
simple solution does not yet exist because EHR producers are focusing on satisfying every need
rather than optimizing around the few that really matter. It’s tempting to succumb to “feature
creep” but EHR producers should remember this seemingly anomaly: the Ford Taurus has more
parts than a Ferrari.7 It’s time for the EHR producers to build their first Ferrari.
Exhibit 1: Shows hypothetical example of how a Twitter style UI could be adapted to transform
into a simple EHR application
Exhibit 2: Screen shots comparing the “feature creep” of today’s purportedly simple EHRs to
equally complex CRM (customer relationship management) software which is much simpler
Works cited

1. Interview, Pete Fox, May 3, 2010. Athena Health Sales Executive

2. Interview, Gerald Godwin, May 10, 2010. Current EPIC consultant
3. Fastest Growing Demographic on Facebook. February 2, 2009. InsideFacebook.com
4. Class guest lecture. Kim LaFontana. May 12, 2010 VP of Strategic Initiatives, Ingenix
5. Facebook prepares to announce 500 million users. May 17, 2010. AllFacebook.com
6. The Laws of Simplicity. Maeda, John. MIT Press. 2006
7. Pareto Principle. Wikipedia. http://en.wikipedia.org/wiki/Pareto_principle