NOSH ChartingSystem

A new open source health charting system for doctors.

Why EHR design matters


Besides the importance of physician happiness when using an EHR, using design principles that maximize user intuition and presentation of relevant information, there is one aspect of health care information systems that should never be overlooked…patient safety.

Scot Silverstein, MD, blogging at Health Care Renewal as InformaticsMD, frequently brings to light issues surrounding health care IT implementations that compromise patient safety.  Reading his posts should be sobering and concerning to both medical professionals and the public alike.  Like I’ve said, health care IT, in my opinion, is still in its infancy despite the number of years computers have been around and the existence of Meaningful Use legislation.

As a practicing physician as well as a software coder, I’ve used a number of EHR’s (and still currently using a well known EHR by my employer of my part time job) to know how some of these appalling user interfaces affect not just workflow and user happiness, but patient safety.

An example of one design element that most physicians may not be able to identify, ironically, is the one that is most harmful when it comes to patient safety. In this well known EHR, you are presented a medication list for a patient. As a physician, you assume that this list is a current medication list and is up to date.  However, the reality is that this EHR system automatically removes a medication from the list when it is determined to be expired even if it should be appearing on the current medication list. When a physician prescribes a medication from this system, it calculates the duration of usage of the medication based on the instructions, quantity of medication prescribed, and the number of refills. Once the duration exceeds the number of days that has elapsed since the prescription was made, the medication is taken off the current list automatically by the EHR. Now, taken at face value, this sounds like the logical approach to manage a medication list and utilizes the computing power that an EHR will gladly show off as a benefit to physicians.

Unfortunately, the EHR programmers failed to understand that medications are not taken regularly by all patients all the time. In fact, no physician assumes that at all. So why should an EHR make that assumption? Furthermore, there are plenty of treatments that are to be taken only as needed so how can an EHR account for that? Absolutely, impossible.

So I recently treated a patient that reportedly has asthma. I happened to look at a previous note and find out that the patient was denied a refill request for Albuterol, a bronchodialator that is meant to be taken as needed. She ended up in a life threatening asthma flare up and needed emergent care. It turns out the physician on call who was given the refill request several days prior didn’t realize that the EHR removed the Albuterol from her list and subsequently instructed that the patient needed to have a physician visit for having the medication prescribed. After going through 2 different windows and unclicking a check box, I was able to identify that the patient did in fact have an active prescription for Albuterol, but the EHR made it disappear. She has used it infrequently, probably because her asthma was well controlled. Unfortunately, she ended up in worse shape when she needed the medication the most.

Most physicians don’t have the time nor the technical know-how to peer through a complicated EHR. Perhaps I normally don’t trust the EHR because I’ve be jaded by bad designs and because I know how to hack around a system when a bad design didn’t give me the information that I want. But this example highly illustrates that a poorly designed EHR that has not gone through a reality test with a practicing physician leaves patient safety in harms way. I ultimately find it appalling that physicians are being peddled multi-million dollar systems that have not had any real practicing physician input in how these systems are designed.

We are beginning to see studies that question the effectiveness of EHR’s when it comes to health care cost reduction and patient safety. One should not make a general conclusion that all EHR’s don’t help, are a waste of money, and have no place in health care. What gets lost in the translation is that an electronic health record system is not the same from one system to an another. Some do a better job than others. What doesn’t get studied is how physician directed user design can affect these results. From other industries where user design is absolutely paramount, including automobile and airplane ergonomics as well as smartphone operating systems and their apps, we know how improved and user informed design makes all the difference in terms of quality output by the user. It’s all about using the right tools for the job. If it can be used intuitively, reliably, and repetitively, you have the right tool for the job. Right now, most EHR’s are like sledgehammers when what we really need are sharp chisels that create works of art.


Author: shihjay

I am a family physician and previous medical director for a child abuse assessment center. I am now promoting my new electronic health record system (NOSH ChartingSystem) that I have developed and used for myself in my private practice since 2010 and now I want to share it to the rest of the doctoring world.

4 thoughts on “Why EHR design matters

  1. I think most people would agree with your conclusions even without hard data that reveals decreased patient safety from poorly designed EHR’s, but EHR’s suffer from many of the same constraints of all enterprise software. The users of the system are not the people that buy the software. Incentives are not aligned for placing ease of use and elegant design at the top of the hierarchy of needs for EHR’s.

    I posit that decades of poor interface design and unintuitive UX has not changed most enterprise software so why would EHR’s be different? On a long enough time horizon perhaps we will see changes but I suspect we are decades and many patient safety studies away from that. if the people that buy EHR’s don’t vote with their money for intuitive UX and patient safety features what would prompt companies to actually build it?

    After several decades of EHR’s entrenched interests will make it even harder to upend the market with simply good design. I feel that if we as physicians continue our learned helplessness and don’t demand that our software change then it never will.

    I sound pessimistic, and I am about the incentive alignment as it now stands, but I’m actually optimistic that we can eventually change this. I think a UX focused EHR (open source or commercial) with a decades-long business strategy could make significant headway if the people using the software found it to be significantly better in the ways that you suggest matter.

  2. Really enjoyed this article. We are taking on precisely this challenge at our company, nGage Health ( as we develop our population health management portal for physicians. Currently trying to take EHR data and regurgitate it into meaningful, intuitive visualisations not just for physician’s but for the populations they serve. We believe that through a user-centred design approach we can reach a standard where both physician and patient can very easily interact with their data AND each other. But I agree with @kgautreaux, there is a long way to go before the EHR vendors seriously invest time and money into usability!

  3. I’m relatively new to the HIT world and have yet to hear any companies in the field talk about “product” and “user experience”. The “winners” will have that as their flagship. Great job pointing out how design not only impacts users but real world health.

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