Standards, Needs, Chickens and Eggs

EHR System Technical Functionality vs. UsabilityStandardized Features Such as the Infobutton

William A. Hyman
Professor Emeritus, Biomedical Engineering
Texas A&M University,
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In a rational world we would collectively decide what needed to be done, and then determine what standardization and associated standards if any were needed to facilitate the doing. Who constitutes the “we” might be the subject of some additional discussion, but that is a subject for another day.

One well known form of EHR standardization is that they should be able to exchange information with each other, both recognizing the information and the patient, and putting both in the right place. Except perhaps for those cared for in a close-knit system, this remains somewhat short of reality. I for one can count a half dozen providers each of which uses some form of EHR, but none of which can directly share data between them other than by fax, e-mail, or hand carried copy.

Another form of standardization could dictate or guide that all EHRs look and feel more-or-less the same so that users could move easily from one EHR to another. While perhaps potentially restrictive, this type of standardization is well known to us in other areas of lives. For example almost all automobiles operate in nearly an identical manner and we can get into almost brand and drive off with essentially no vehicle specific training. This is a key factor in the rental car industry; although I admit I have struggled with lights and wipers from time to time, and once drove too far too fast in second gear in a vehicle that had both automatic and clutch-less manual capability.

A particular aspect of EHR look and feel is for each to have standardized features such as the Infobutton. This is a good example of the opportunity to collectively decide what the Infobutton should do, and then create the necessary standards. But here, it turns out, the Infobutton standard has gotten ahead of the implementation, such that the implementation criteria are now being modified to accommodate the capabilities of the Infobutton. As the ONC wrote in the recent Federal Register announcement of the Voluntary 2015 Edition Electronic Health Record (EHR) Certification Criteria; Interoperability Updates and Regulatory Improvements (2/25/14), it has “received clarifying feedback” that the Infobutton standard does not support vital signs and medication allergies data for linked referential CDS. As a result, ONC proposed that the 2015 Edition CDS certification criterion not require compliance with the previously assumed Infobutton-enabled capability. Similarly, ONC proposed to discontinue referencing laboratory values/results data as they “understand from stakeholder feedback” that the Infobutton standard cannot support this specific data. For the same reason ONC proposed to drop the requirement that EHR technology be capable of electronically identifying patient-specific education resources based on “laboratory values/results” because the Infobutton can’t do it and they “do not expect EHR technology developers to develop an alternative method.” The latter I suppose is good news for the technology developers, but not necessarily good news for the improvements in healthcare that EHRs are supposed to bring.

In summary, what was once thought to be useful features of EHRs are now found to not be compatible with the Infobutton standard which was created at least in part ahead of the determination of all of the things we might want the Infobutton to do. This left three choices: revise the Infobutton capability standard, require the EHR attributes anyway without reference to the Infobutton, or drop the feature. ONC chose the latter, opting for not having eggs because they didn’t have a chicken to provide them.