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EHR Design Talk with Dr. Rick 6/20/12

June 20, 2012 Rick Weinhaus 13 Comments

Special Edition: The ONC/NIST Workshop on Creating Usable EHRs — Part 2

If you ask clinicians which aspects of their EHRs drive them nuts, many can tell you in some detail. On the other hand, if you ask them how to improve those EHR designs, most cannot articulate the issues in ways that would lead to fundamental change. Relying on focus groups and implementing user requests turn out to be similarly unproductive.

If these methods don’t work, how should one design EHR software that meets the goals and needs of its users and thereby improves healthcare?

There are no simple answers. After all, EHR software is a very new cognitive tool.

An alternative to asking users for advice and feedback is to apply rational design methods collectively referred to as User-Centered Design (UCD). This was the focus of last month’s ONC/NIST Workshop.

Since my last post, I’ve been thinking a lot about the term User-Centered Design because it has two distinct definitions.

On the one hand, it can mean design based on our understanding of how the human brain best takes in, organizes, and processes information — in other words, Human-Centered Design. By this definition, UCD encompasses not just usability testing, but also the findings and methods of a number of related fields, including interaction design, data visualization, cognitive science, and human factors.

On the other hand, the term User-Centered Design can refer to a relatively codified method of software design that places emphasis on setting user performance objectives, conducting iterative user testing during development, and ultimately performing formal summative usability testing to evaluate the end product.

I prefer the first definition because it places more emphasis on the design process itself. A design process that brings together the findings and methods of several fields is more likely to foster innovative solutions. One comprehensive design approach I particularly like is Goal-Directed Design, as described by Alan Cooper, Kim Goodwin, and colleagues in their complementary books About Face 3 and Designing for the Digital Age.

The next question is what role, if any, should ONC play in regard to User-Centered Design and EHR usability. There are two basic philosophies on how to improve EHR design and safety.

One approach is to encourage innovation by allowing market forces, including those created by disruptive innovation, to work. The other approach is to regulate the evaluation process — for instance, to require summative usability testing, to have the FDA regulate EHRs as medical devices, and so forth.

While everyone wants safer EHR designs, in practice it’s not clear to me that more regulation will help. Because of the complex and interactive nature of software user interfaces, evaluating the safety of EHRs is orders of magnitude more difficult than evaluating the safety of physical devices.

An EHR can follow a long list of guidelines, pass all kinds of usability testing, and still present the user with terribly problematic interfaces. After having studied the NIST, AHRQ, and HIMSS documents related to EHR usability, I don’t see how mandating formal usability testing is going to make EHRs safer.

For one thing, one usability guideline inevitably conflicts with another. Furthermore, while summative usability testing is reliable and yields quantitative data, exactly what gets tested is highly subjective. Third, evaluating the safety of EHR software is a moving target, as the software development tools, the design patterns, and the platforms are all changing rapidly.

It is clear that ONC has been considering the role it should play in regard to EHR usability. While we don’t know what ONC’s final rules on User-Centered Design will be, we can glean some information from last month’s workshop.

In their presentations, National Coordinator Farzad Mostashari and ONC’s recently appointed acting Chief Medical Officer, Jacob Reider, made the following points:

  • The UK model, mandating a particular EHR design, clearly didn’t work.
  • Getting feedback from clinicians is generally a poor way to improve EHR design. As Henry Ford remarked about his cars, “If I had asked people what they wanted, they would have said faster horses.” The UCD process, broadly defined, is a better way to improve design.
  • Market forces should work. The more usable EHRs will be the successful ones. Vendors who understand these issues will make User-Centered Design a high priority instead of focusing on new "bells and whistles."
  • It has taken the aviation industry a hundred years to learn how to build safe planes. Health Information Technology (HIT) is a young industry. Transformation will not occur overnight.
  • ONC does not see its role as defining how an EHR should look and feel. Rather, its main concern regarding usability is safety.
  • The tradeoff between innovation and safety is not a "zero-sum game." With more usable designs, everybody wins.

It would appear this same perspective is reflected in ONC’s March 2012 Notice of Proposed Rule Making (pp. 13842-3). First of all, ONC proposes to limit the UCD process to eight certification criteria, all related to the high-risk area of medications. Secondly, the notice states:

… we believe that a significant first step toward improving overall usability is to focus on the process of UCD. While valid and reliable usability measurements exist … we are concerned that it would be inappropriate at this juncture for ONC to seek to measure EHR technology in this way … Presently, we believe it is best to enable EHR technology developers to choose their UCD approach and not to prescribe one or more specific UCD processes that would be required to meet this certification criterion.

Unless innovative designs are allowed to emerge, the next generation of EHR user interfaces will continue to have all the major usability problems of our current ones. From my perspective as a physician EHR user who also thinks and writes about EHR design, I’d say that ONC got its User-Centered Design policy just about right.

Rick Weinhaus MD practices clinical ophthalmology in the Boston area. He trained at Harvard Medical School, The Massachusetts Eye and Ear Infirmary, and the Neuroscience Unit of the Schepens Eye Research Institute. He writes on how to design simple, powerful, elegant user interfaces for electronic health records (EHRs) by applying our understanding of human perception and cognition. He welcomes your comments and thoughts on this post and on EHR usability issues. E-mail Dr. Rick.

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13 Responses to “EHR Design Talk with Dr. Rick 6/20/12”

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  1. 14
    Chuck Webster MD MSIE MSIS @EHRworkflow Says:

    Reasonable people can differ on this and only time will tell!

    Would like to stay in contact re this issue…



  2. 13
    rm Says:

    I agree, Chuck – I only used “unfortuntely” because what’s being implemented today is far from what I think both of us imagine that is needed / wanted.

    I’m less optimistic than you that markedly better systems will supplant what’s being implemented, even with widespread end-user dissatisfaction. Over time, end users will learn to live with the pain (or have others do the typing) and the systems will be used administrivially instead of for all of the things that could actually make a difference in patient care.

  3. 12
    Chuck Webster MD MSIE MSIS @EHRworkflow Says:


    “EHRs should resemble (or be) BPM systems. Unfortunately this would require total re-imagination and development of today’s EHR systems…and the purchasers of EHR systems to take out the workflow-slowing stuff they bought (customized, interfaces, trained everyone on, etc.) and replace it with something new (albeit potentially better in many ways).”

    I agree with every word, except “Unfortunately”. “Re-imagination” and “something new” are exactly what the EHR and HIT industry needs.


    1. Business process management (BPM) and adaptive case management (ACM) vendors are eager to partner with healthcare organizations and vendors. Many already do substantial healthcare business, though usually not at the point-of-care (yet).

    2. EHR users are restive, increasingly critical of the workflow-challenged systems they feel forced or bribed to use.

    3. And some EHR & HIT vendors have more customizable workflows than others. They may not think of themselves as EHR BPM systems (yet), but in effect they are, or at least becoming so.


    Educate EHR users and HIT buyers, find the right EHR and HIT vendors, increase prevalence of BPM and ACM technology, that’s the fortunate path forward. Yes, it threatens status quo. Good. Cloud, mobile, social already do. Why not add BPM to the mix?

    As a matter of fact, BPM vendors are further along than HIT vendors in use of cloud, mobile, and social technology. As such, cloud, mobile, and social will be important “vectors” for transport of BPM’s process-aware ideas and technologies into healthcare.


    So, “Fortunately”! (Just a quibble though! We’re on the same wavelength.)


  4. 11
    rm Says:

    Dr. Rick said: “For these reasons, it seems all the more important for EHR developers to devote adequate time and resources to the design process itself. In my opinion, if the high-level EHR design is poorly conceived, usability testing can have limited impact at best.”

    I’m in 100% agreement, Dr. Rick! And summative (validation) testing will be a big waste if the developers haven’t conducted formative testing (and don’t have a good understanding of the users, their tasks and workflows). It all works together and it is all necessary (especially for mission critical systems).

    I also agree with Chuck Webster that EHRs should resemble (or be) BPM systems. Unfortunately this would require total re-imagination and development of today’s EHR systems…and the purchasers of EHR systems to take out the workflow-slowing stuff they bought (customized, interfaces, trained everyone on, etc.) and replace it with something new (albeit potentially better in many ways).

    HITECH ensured that healthcare organizations (especially health systems) will have the systems that they have now for many years and real platform-blowing-up innovation took a back seat to unimaginative (but on time!) roll-out of MU requirements.

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