Quality in the EHR is a zero-sum game, involving a balancing act among three key but competing needs: scope, resources and usability.

This is a concept most New Englanders are familiar with from the popular sign in local diners:

Whether one is talking about building or deploying an EHR, creating software, or building a complex system, one has to accept that - in our finite universe - there are some inescapable limitations. In software development this is often referred to as the ‘Iron Triangle’ of scope, cost and speed. This model can easily be adapted to the EHR, where usability replaces speed:


Scope relates to how much the EHR will do. How much data will it hold? How much internal logic will it contain? What sort of functions will it offer?

Resources relates to how much it costs to build, to install, to update and maintain, and to support.

Usability relates to how easy it is to use? How long does it take to become proficient and efficient? How readable is it on screen? How flexible it is in terms of adjusting to work flows rather than driving (disrupting) work flows? How intuitive is it?

Maximizing one or two attributes will always require sacrifices in the remaining attributes:

  1. A powerful EHR will either be very expensive to create/maintain or hard to use, or both. 
  2. An EHR that is inexpensive to build and support will have limited scope or limited usability, or both.
  3. An EHR that is intuitive, easy to use, and easily adapted to different work flows will either have to sacrifice power or will require expensive support. Or both.

This makes it very easy to understand why more than 2/3 of clinicians complain bitterly about the EHR they are using, usually citing lack of usability as the problem. And why about half of clinicians surveyed consistently say the EHR has not significantly improved the quality of care they deliver. The people who create EHRs focus on the primary needs of their customer base - which is not clinicians but primarily institutions and secondarily payors. The systems that buy EHRs (and therefore drive what they contain and how they work) are interested in a product that will be powerful enough to collect the vast data they need for billing, medico legal documentation, and satisfying a myriad of external audit requirements; and they want it to be as inexpensive as possible and as easy to support as possible. Note that clinical usability is something the primary customer does not highly value, and likely doesn’t understand.

As long as the EHR is designed for and sold to large medical institutions, the actual clinical usefulness will be the lowest priority. Focus on clinical usefulness will only happen when (if) clinicians and patients are the primary customers. I just wish I knew how to make that happen. My fantasy is that patients will start demanding that their clinicians use a system that is designed with medical care and patient-clinician collaboration in mind. “If you want to be my doctor, you need to be willing and able to use an information system that lets me see and use the information, including deciding who has access.”  We need some systems in place that do this, in order to pressure the rest of the medical world to keep up or fade away.




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