I can remember one summer in middle school when I would tear around my neighborhood on my bike for hours. The long, hot summer days were the perfect opportunity for me to ride around like any other kid. I didn’t have any destination in mind, I just went to ride, for the sake of the journey. I didn’t usually have friends with me, but I didn’t care. I was lost in my own thoughts and ideas. One such idea was a bit ridiculous. That idea was to outfit neighborhood kid’s bikes with trailers and ship lemonade packets, supplies, and money around to create a chain of lemonade stands. Every stand would be a subsidiary of the stand I ran (of course) and would take daily deliveries from a squad of bike delivery riders. Looking back, this was a pretty rudimentary idea. How do you possibly get 10 –13-year-olds to cooperate on something like that? Who’s buying the lemonade? Is there even enough demand for an entire chain of lemonade stands?
However, at the time, none of that mattered. What was exciting was the possibility of a venture. The possibility of making and building something. The journey of creation was exciting and even more so when the possibilities (to a 12-year-old) were endless.
I think that this mentality is why I became a designer. Design practice makes things happen. For better or worse, most everything you create as a designer has the ability to make someone’s life better, convince them to do something, inspire them, or show them a different perspective. And while that statement may sound hyperbolic, just look at Facebook or Instagram and their influence in culture, politics, and religion. Or look at Shopify or Salesforce for business, commerce, and collaboration. The design of things impacts our lives and shapes how we perceive and interact with the world around us.
Several years ago, I stumbled upon a significant problem. Or as Jim Collins puts it, the BHAG… the Big Hairy Audacious Goal. The systems that our healthcare professionals use, referred to as EHRs, are, to put it mildly, awful. In fact, they’re so awful that the American Medical Association has documented what they recommend providers do to make them easier to use. This set of recommendations, published in 2014, outline challenges and recommended solutions to make EHRs easier to use. These challenges and solutions are things that designers and consumer-based tech companies have been figuring out for years.
Here are a few examples:
In addition to this report, I’ve felt the first-hand effects of these issues presented by current EHR systems. Throughout my high school and college years, my dad always worked long hours due to the inefficiencies of the EHR that his practice used. I know that the long hours often 5:30 AM to 8:00 PM took a toll on him emotionally, physically, and mentally. Once I asked him to show me why the system was so difficult to use. He pointed to several usability issues within the interface and remarked how to complete one task required 40 clicks to finish.
When I read this report and knew that the problems I witnessed weren’t isolated or anecdotal, my reaction was astonishment and disbelief.
“These are all things that I’ve been studying and practicing for years,” I said to myself. “Surely someone has already started working on this.” But as much as I looked I couldn’t find anyone working on this. Sure there were tons of mockups and comps on Dribbble but none of those dug into the problem at scale and (as far as I know) none of them have been turned into real companies.
An idea began forming in my head, it seemed and still seems crazy, outrageous, and ridiculous. My BHAG if you will…
You should redesign the EHR, from the ground up.
See how dumb that sounds? One person, redesigning a giant system. One person, taking on a multi-billion dollar industry. One person, who doesn’t even design “products,” designing a product that could disrupt an entire industry. Just like my lemonade stand empire, I was excited. The venture awaited. The idea begged for my attention. It dominated my thoughts. I didn’t care about potential issues. Call it naivety, call it stupidity, I knew I had to try.
Armed with this knowledge and my own personal experience, I began to do some more in-depth research. I found an excellent resource that connected me with physicians across the country to talk to. I jumped at the opportunity to hear directly from the source(s). I put out a “job ad” on the platform asking for help in designing the next generation EHR. The responses astounded me. Telemedicine, family physicians, medical students, residents, specialists, large hospitals, small hospitals, independent practices. I received so many messages that I could hardly keep up with setting up phone calls. I knew I’d struck on something big.
Once I explained my goal, it was like a faucet opened. Everyone had so many ideas and almost everyone had stories about issues they’ve run into either personally or professionally due to their EHR’s design. Many of these anecdotes revolved around why they became doctors, to take care of people, not to be data input specialists. Many doctors voiced concern over how the software consistently gets in the way of actually accomplishing the work that they need to do. Not only that, but stories of long hours and depressing work were common.
Unfortunately, this isn’t isolated to these individual interviews, nationally, physician burnout is on the rise. While not all the reasons for burnout can be attributed to the technology behind EHRs, technology is a big contributing factor to it. According to the Medscape National Physician Burnout, Depression & Suicide Report 2019, nearly 60% of physicians who report being burned out say it is due to bureaucratic issues related to charting. While there are many factors behind charting practices, such as insurance coding, HIPPA regulations, and practice and hospital requirements, the usability of the EHR is often a large contributing factor.
So the question, remains, why has no one tried to redesign the EHR? Of course, people have tried. However, the efforts usually run into one of five problems.
The first and most obvious problem is money. Conservative estimates put a full redesign and rebuild at around $200M to start. That’s a large number. The design, engineering, support, and security needs for such a system are enormous. Hardly within the realm of the bootstrapped, move-fast-and-break-things mentality. And you don’t necessarily want to break things when people’s lives are on the line.
Breaking into the market is difficult. When hospital systems routinely spend millions if not billions of dollars to implement EHRs, the likelihood of them jumping to a new solution is slim. The EHR is a once-every-few-decades decision, not once every 2–3 years. Additionally, scaling to an enterprise solution to fit the largest hospital systems is nearly impossible right out of the gate.
Perhaps the most contentious problem is that the current EHRs work, but not for the end user. They work for data mining and payment very well, but not for physicians or nurses. So the hospital systems make money and work with insurance companies, but in the end, the caregivers are the ones who suffer.
The fourth problem is that no one can really seem to agree on the best way to handle the workflow of an EHR. There are entire consultancies devoted to helping practices improve workflow, communication, and patient care. But still, the jury seems to be out on whether the SOAP note method is the best way to document or if there is a different method that is better. And more importantly, how that SOAP note is translated into a digital space is rather difficult. How does one build a system for an industry that can’t really figure out the exact right way to do the work they do?
The fifth and final problem is the feature set. There are so many features that need to be designed and integrated together that the scope becomes massive almost immediately. Of course, feature prioritization isn’t new and is possible, but when they’re all required for every facet of the business, the challenge becomes incredibly daunting.
Innovation is driven not by limitless abilities, budgets, and timelines, but by the limitations imposed by real-world problems.
The realities of these problems don’t scare me, that much. The realities of these problems are the constraints of designing a product. And if there’s one thing designers love, it’s constraints. Not necessarily because of perceived limitation, but because of the ability to surprise, innovate, and delight within those limitations. Innovation is driven not by limitless abilities, budgets, and timelines, but by the limitations imposed by real-world problems.
I see many companies and industries that have innovated through similar problems that have created massive disruption to their individual industries.
For instance, Shopify has done many of the same things for eCommerce. Shopify takes what typically is an arduous, difficult process to design, build, and implement an eCommerce store and made it efficient, easy, and simple for the smaller merchant. Within fifteen minutes anyone can have a store up and running. And while they’re not the only ones doing it, they’ve been (arguably) the most successful due to their focus on the merchant’s needs, their attention to design and ease of use, and their ability to respond to changing needs.
In a way, you could say that that this project aims to be the Shopify of healthcare. While the problem exists at all levels of healthcare administration, smaller offices and outpatient facilities are potentially easier to build for than large, multi-site hospital systems. A cloud-hosted solution makes a lot of sense for them. Large technical overhead is a major pain point and not having to worry about security can help many practices focus on the business. Additionally, practices with 1–30 physicians make up 72% of the market. Certainly, a practice with 5 or 15 physicians can’t afford a $200M EHR implementation. So designing for their needs and ensuring data interoperability with other EHRs is not quite the humongous battle that others have faced.
Regardless, the challenge is still enormous, yet the potential inside this opportunity is so exciting. While this could fail epically, it’s certainly better to try than always wonder what if. The journey here is not about the destination, but about the learning, opportunities, and people I’ll meet along the way. The journey is about helping the thousands of doctors experiencing burnout, the doctors maybe contemplating suicide, and the nurses figuring out how they’ll make it home for their children. And ultimately, it’s for the communities and families they take care of.
For the time being, I’ll be starting with small steps, small chunks of the problem and figuring out how they tie together.
Start small to go big and change the world.