Time Capsule: If EMR Vendors Designed Cars, the Steering Wheel Could Be Anywhere: Why a Universal Physician Interface Makes Sense (and will never happen)

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in November 2008.

If EMR Vendors Designed Cars, the Steering Wheel Could Be Anywhere: Why a Universal Physician Interface Makes Sense (and will never happen)
By Mr. HIStalk

I used to work in a two-IDN town. In fact, I had worked in the IT department of both of them (not at the same time, unfortunately, since that would have been a sweet paycheck).

Both IDNs bought big-ticket inpatient clinical systems within a few months of each other. Those who have worked in a two-hospital town or remember the Cold War understand this instinctively.

As inevitable as it was that rumors of one of us buying a system sent the other scurrying to draft an RFI, it was preordained that we would not consider the same vendor. Whichever IDN bought last would look like an unimaginative lemming, so there was no doubt that two vendors would be shuttling people into town for years.

I was shocked that the local newspaper not only cared about our respective deals, they took both IDNs to task in a rather scathing editorial for going our separate ways. In their minds, we had blown a golden opportunity to finally agree on something other than the fact that one of us was a plainly second-tier system (which one was another thing we didn’t agree on).

From a community perspective, they were probably right. Both places served mostly community-based physicians who practiced in hospitals of both IDNs. Our ruggedly individualistic decisions meant that most of the doctors in town would not only have to learn to use an EMR to keep in our smothering good graces (since ROI was dependent on massive, yet unlikely voluntary physician usage). They would have to learn TWO systems with nothing much in common except they both had a screen and a keyboard.

(That allowed us both to argue that we had chosen a better system than our cross-town loser competitors. In addition, there were only three real vendors that would have been acceptable and one of those was a little shaky at the time, so we went out of our way to avoid consensus).

Vendors would never object to this, of course. Software that looks and works alike has a name: “commodity.” In that respect, vendors had as much interest as we IDNs did in bucking the trend set by our competitor or vice versa.

Here’s an interesting idea, though. Why couldn’t CPOE and EMR systems have the same common user interface? They provide and accept the same basic information. Are screens really so highly proprietary and ingenious that they can’t be the same on all systems? Couldn’t they put their high-margin secret sauce somewhere else, like in clinical decision support, scalability, cost, or maintenance quality?

(You could almost make this happen in the old character-based days by using screen-scraping applications to redesign the front end, like Attachmate or programmable fake Windows front ends).

Everybody always says, “You can use a browser without reading a manual first.” As annoying as that statement is, everybody is right. Browsers, cars, TVs, and credit cards all look and work pretty much alike to the user. That increases adoption, yet still allows plenty of criteria on which vendors can compete and differentiate.

Physician systems operate under the most bizarre paradigm of any software application. The organization that buys them isn’t the one using them, for the most part, since doctors are self-employed (unlike pharmacists, rad techs, nurses, etc. who practice in just one place using just one system). Usage is voluntary and therefore sporadic. Those voluntary users (who are really our customers) are supposed to deal with it, show up for training, and read ongoing messages about bugs, upgrades, and downtime (times two or three, depending on the town).

If I were HIT King for a Day, my second decree (after putting a spending cap on HIMSS exhibits) would be this: every system intended for physician use will employ a common user interface whose visible appearance, terminology, and user interaction is fixed. Vendors who fail to comply will have their kneecaps broken by CCHIT.

What vendors do behind the scenes is their own business, but when you’re selling cars, no matter how clever your designers are, the steering wheels and pedals need to be in the same place if you want to move iron.