EHR Usability: It is NOT a training issue

In a recent blog post by John Lynn, (of Healthcare Scene fame) , John discusses the irony of the following two statements:

  • EHR Training Improves EHR Satisfaction and
  • Physicians Don’t Want to Make Time for EHR Training

Many, many times in our usability evaluation and design career when a development team isn't really interested in making enhancements to fix specific issues that we've identified, we've heard something like the phrase, "There is nothing wrong with the user interface, it is a training issue."

This very engineering-centric attitude is all too prevalent. These teams are more interested in getting any product out the door, and are not interested in supporting the needs of real people that have to use it.

"THEY (the users) can't figure out how to use it, so THEY need training."

A key component of the Human-centered Design paradigm is empathy. Empathy and understanding of real user's needs leads to a product that can match the mental model and workflow of users.

The theories of Jean Piaget can also be applied to understanding the reasons why many EHRs are just too hard to use and why they require so much training. According to Piaget, people are born with a very basic mental structure or schema on which all subsequent learning and knowledge is based.

Medical professionals have many schemas they use in their practice. Seeing and treating a patient can most often follow a set pattern, or workflow: The patient arrives, vitals are taken then entered into the patient record, the doctor consults with the patient, possibly orders tests, or prescriptions, etc.

So, what happens when the real world does not match an existing schema? As we gain more experience with the world, our schema must evolve via the processes of learning. According the Piaget the learning takes place via the processes of Assimilation and Accommodation. See Jean Piaget & the Usability of Healthcare Software

Assimilation occurs when you can take an existing mental structure and easily incorporate it into understanding a new event or system. Assimilation does not cause much cognitive load on the person, as they are using an already existing mental structure to understand things.

Accommodation occurs when you must change your mental structure in order to understand and incorporate a new event. Accommodation requires much more of a cognitive load than assimilation, as it requires you to ‘rewire’ your brain and update or create a new mental structure to understand the event.

Basic functionally of the system should be easy for users without training. EHR users should be able to assimilate, not forced to accommodate, the basics of using the EHR into their current mental structure.

When we design EHRs that make "more sense" to physicians, they will not need as much basic training. Physicians can instead use training to leap-frog the transition from a novice to expert user by learning from the Subject Matter Expert. Having a subject matter expert discuss the ins-and-outs of a system, and provide various best practices and work-a-rounds to get the job done can be very valuable. Maybe with this schema physicians will not be so resistant to training.