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Monday Morning Update 5/31/10

May 29, 2010 News 51 Comments

From Tabula Rosa: “Re: EMR usability. At one of the ONC Policy Committee meetings, Judy Faulkner of Epic supposedly declared that ‘usability would be part of certification over her dead body.’ I wonder if she has similar sentiments about making software accessible to people with disabilities?” Unverified. This inspired my new poll question – keep reading below. 


From ExXeroid: “Re: The Hospital of Central Connecticut. The Cerner staff is down to a skeleton crew. The IT people are leaving in droves. Cerner KC is the ACS takeover, but there’s hardly anyone left to support internally after the ACS disaster.” Unverified.


From The PACS Designer: “Re: Apple’s OS 4.0. Apple’s iPhone OS 4.0 will be available for the iPhone this summer and for the iPad this fall. While we are waiting, we get the opportunity to see some of the features that are coming. Also, Apple has a developer’s Web site to aid those who want to venture into application development for the OS 4.0.”


HIStalk readers donated generously to Sumter Regional Hospital (GA) after it was destroyed by a tornado in March 2007 (we collectively donated $11,264). The hospital, now Phoebe Sumter Medical Center and still being rebuilt, later received what appeared to be the highest vote total in a Siemens-sponsored contest to win an $800K Magneton Essenza MRI scanner, but somehow lost to another facility. Siemens decided to donate a machine to Sumter anyway. It has arrived and is already being used, with the picture above being one of the hospital’s first patients to benefit from it last week. The ribbon cutting will be this Friday, June 4 at 10 a.m. Former President Jimmy Carter, a Sumter County resident, may attend.


A whopping 79% of HIStalk readers say they would worry about the confidentiality of their electronic information if they had a psychiatric illness and their providers were sharing information electronically. That’s not to say that they are specifically concerned about electronic security, only that they would worry about having their information exposed in some unspecified way. New poll to your right: what’s the best way to raise the level of EHR usability in the marketplace?

I figured it was time to cruise around the sites of some of HIStalk’s sponsors and see what’s new with them.

  • Rockingham Memorial Hospital (VA) says its use of Nuance’s Dragon Medical and eScription speech recognition products will save it $600K this year alone.
  • A BridgeHead Software survey (warning: PDF) finds that hospital data storage needs are increasing dramatically, primarily because of PACS images, electronic medical records files, and scanned documents.
  • Virtelligence will be exhibiting at MUSE this week.
  • Lakeridge Health Network (ON) selects Access Intelligence Forms Suite to get forms into Meditech scanning and archiving without manual indexing. Access will exhibit at MUSE this week.
  • Registration for the e-MDs user conference in Austin July 22-24 is open. It sells out every year.
  • Ingenix Consulting SVP Joel Hoffman is named a “Top 25 Consultant” by Consulting magazine for his work in assessing financial outcomes of care management.
  • Renaissance Resource Consulting has open positions for Epic installers and IDX/GE application and technical consultants.
  • A native iPad version of PatientKeeper Mobile Clinical Results is now available.
  • CynergisTek CEO Mac MacMillan is quoted in a new article called OCR Building HIPAA Audit Plan With Outside Help.
  • Going to AHIP Institute in Las Vegas next week? MEDecision is hosting a party at PURE in Caesar’s Palace. You know from HIMSS that they throw a good one.
  • O’Toole Law Group is offering (warning: PDF) contract assistance for Meditech 6.0 upgrades.
  • Universal American Corp., a provider of Medicare Advantage and Part D prescription drug plans, chooses (warning: PDF) MedVentive’s care collaboration tools for members and providers, including real-time care and drug substitution recommendations.
  • Charge capture automation vendor MedAptus will exhibit at HFMA’s Annual National Institute later this month in Nashville.
  • Surgical Information Systems will exhibit at MUSE and HFMA this month.
  • ACHE will publish a book on how consumer behavior is changing medicine by Lindsey Jarrell and Colin Konschak, partners of DIVURGENT Healthcare Advisors.
  • Dentrix Enterprise is offering a free Webinar on the features and benefits of its Electronic Dental Record solution, the leading EDR in community health centers.
  • Sunquest will exhibit this month at G2 Lab Outreach in Baltimore and Smart Health in London.
  • Sentry Data Systems releases two case studies on using its Sentinel RCM 340B solutions, one from Alegent Health and the other from Saint Barnabas. They’ll be at HFMA and ASHP this month.
  • Software Testing Solutions introduces its automated testing solution for Eclipsys Sunrise order entry that saves staff time and documents testing of procedure ordering, billing, interfaces, and validation of new releases.
  • MED3OOO has June 3 and 17 Webinars on Assessing Readiness for Meaningful Use, presented by CMIO Jay Anders, MD.
  • EHRScope has gone live with its EMR review site, where EMR users can read and write reviews and rate their product.
  • Vitalize Consulting Solutions is #2 on the KLAS list of consulting firms that providers are considering.

Ed Meagher, former VA deputy CIO, CTO, and chair of the committee that prepared the VistA report that I mentioned last week, took exception to my comments about those committee members with ties to federal contractors. He said, “The [HIStalk] level of cynicism is almost toxic. I can tell you that the personnel who participated in the report did so as IT industry experts, veterans, and citizens and not as representatives of their companies.” I wasn’t doubting their integrity or lack of good intentions, but rather the inevitable and often subconscious world view that any company’s employee would bring to the table. He’s right that the real to-do is to review the report and suggest improvements. Feel free to e-mail your comments and I’ll publish them. Assume that the VA is correct in its assessment that VistA has become technologically obsolete, hard to enhance, and hard to support — do the committee’s recommendations make sense? (although we’re missing a big piece of the puzzle – the inevitably large price tag. The VA is huge, although I can’t readily find its total inpatient bed count.)

I also got some feedback on the AHRQ report on practice EMR usability that I mentioned. I said it was nice work, just limited in applicability because only eight EMR vendors were interviewed and most of the big ones weren’t on the list. From my source, apparently many more EMR vendors were asked to participate, but declined.


HHS CTO and athenahealth co-founder Todd Park is named as one of Fast Company’s 100 Most Creative People. He was recognized for making public health data more readily available. “It’s insufficient to just put data out there. We want to market them to people who can turn them into supercool apps.” Maybe he earned bonus points for correctly using “data” as plural. Cleveland Clinic CIO Martin Harris was #12. Both lost out to #1, Lady Gaga, but I’m sure she’ll sell more magazine copies, at least outside of healthcare.

Sevocity offers regional extension centers and educational organizations free access to its Internet-based EHR, set up as a demo clinic for up to 20 users and requiring them to have nothing more than PC with Internet access.

Inga has the latest in her series of questions for vendor executives: what advice do they have for David Blumenthal? She got some surprisingly frank and diverse answers, ranging from “start an EMR Lemon Law” to “stay the course.”

TELUS Health Solutions will announce this week that it is offering pre-built interface tools from Iatric Systems for quicker, cheaper interfacing of its Oacis EHR to Meditech. Offerings from TELUS include the Oacis Unified Patient Record (a Web-based clinical portal with longitudinal information), Oacis CDR, Oacis HIE, a data warehouse, and capabilities such as CPOE, clinical documentation, and ED tracking. TELUS will exhibit at MUSE this week. Frank Clark, CIO of Medical University of South Carolina, has told me several times that TELUS Oacis is a key part of his organization’s clinical systems strategy, particularly its physician portal.

I did some cleanup of the HIStalk e-mail update mailing list. Spam blockers (not on my end) were keeping some users from receiving their updates, so if you aren’t getting yours, you should now be able to sign up again at the upper right of the page.


I’ve been working on an HIStalk Toolbar for Firefox and IE (not for Chrome since it doesn’t support toolbars, unfortunately). I included some cool features: a search box that allows searching the Web as usual or HIStalk specifically (click the dropdown beside the Go button to choose); a Links dropdown with one-click access to all HIStalk sites; RSS feeds; an e-mail checker that will notify you when new mail comes to your online account (Hotmail, Yahoo, Gmail, etc.); a really cool radio player that I preloaded with some indie rock stations (you can choose any others easily); and a local weather widget. You can customize any or all of this easily. I’ve been using it at work and it’s really handy, especially the e-mail checker and radio player. It uninstalls easily in case you change your mind. I’m listening to the Indie Rock station on it right now and sounds super.

Cerner’s Neal Patterson still wants insurance companies to die (go, Neal!) but also says Cerner will become a healthcare company, not just a healthcare IT company.


Dell announces its Healthcare Print Station, which offers one-touch options to route orders from hospital nursing stations to the pharmacy, a “Scan to EMR” button, a forms-on-demand option, and card copy for scanning both sides of patient ID cards to a single sheet of paper. The $599 add-on is available for Dell’s Java-capable multifunction printers (3333dn, 3335dn, and 5535dn).

NextGen parent Quality Systems reports Q4 numbers: revenue up 19%, EPS $0.45 vs. $0.40, falling short of consensus earnings expectations of $0.49. 

Happy Memorial Day! Except for you non-US readers, who I confess I wasn’t thinking about when I talked about the holiday last week. Thanks to the reader from Canada who reminded me. According to my stats, the leading countries for HIStalk readers other than the US are Canada, Australia, UK, and India, with a significant drop-off before the next group from Ukraine, China, Israel, and France. As the programmers say, Hello World.

E-mail me.

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Currently there are "51 comments" on this Article:

  1. Re: ” EMR usability. At one of the ONC Policy Committee meetings, Judy Faulkner of Epic supposedly declared that ‘usability would be part of certification over her dead body.’

    If this is true, let me translate:

    I’m an ultra-arrogant a*hole, and f*** the doctors and nurses, and f*** the dead bodies of patients killed by HIT with poor design.

  2. Re: “Ed Meagher, former VA deputy CIO, CTO, and chair of the committee that prepared the VistA report that I mentioned last week, took exception to my comments about those committee members with ties to federal contractors. He said, “The [HIStalk] level of cynicism is almost toxic. I can tell you that the personnel who participated in the report did so as IT industry experts, veterans, and citizens and not as representatives of their companies.”

    Mr. Meagher needs to read the cases at the following URL to understand why accusations of HisTALK “cynicism” do not impress me: http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest

    He might also read http://hcrenewal.blogspot.com/2010/05/at-upmc-dealings-with-board-members.html , as the revelations that will come from future 990’s on conflicts of interest might just turn what he calls “cynicism” into prosecutions.

  3. >>> Inga has the latest in her series of questions for vendor executives: what advice do they have for David Blumenthal?

    Inga- just wanted to let you know that Dr. Blumenthal now has an interesting thread where he is asking folks to post some positive “meaningful use” stories to share. URL: http://healthit.hhs.gov/blog/onc/index.php/2010/05/27/health-it-journey-stories-from-the-road/comment-page-1/#comment-914

    Of course I put in my 2 cents (my letter to the editor is still pending “moderation”), starting with:

    “It’s kind of pathetic when you have to beg those trying to use “meaningful use” EHR for nice stories and after the initial 48 not get even one small positive note.

    You asked for [my] story… ”

    If he doesn’t post it over the long weekend, the full text can also be found here- http://www.emrupdate.com/forums/t/24168.aspx


  4. Great question re: Usability and options for the survey. Usability starts with education. If you do nothing except use the term, vendors will co-opt it and turn it into their own tool creating more FUD. If you go the “CCHIT” route (“independent” vendor certifications), it will turn into another monopoly maker where the bigger vendors run the show with some esoteric definitions. Incorporating it into standards is the second step, after education has begun. We need to agree, as an industry, what usability is, what it isn’t and then make it so it can be objectively evaluated.

  5. Love the HIStalk Toolbar! One correction, you’ll have to reboot your system for the change to take effect. TPD!

  6. Regarding the Faulkner usability statement: I detect the odor of fraud on the people. What she said is consistent with the crap the health professional are forced to use. There are too many industry foxes guarding the hen house.

    Why is she, or any HIT industry self interested parties, on these committees deciding the fate of medical care in the United States?

    Mr. Histalk, we urge you to seek the transcripts of said meeting and to ask the chief Blumenthal if he would testify under oath as to what she said, exactly.

  7. According to the CCHIT web site here: http://www.cchit.org/products/2011/ambulatory/1854, EpicCare Ambulatory got 5 stars for usability, although it’s nearly impossible to find out what that means (CCHIT doesn’t make its criteria very easy to find, so is that 5 stars out 5 possible? Show me where I can find out!!!)

    Anyway, my point was that it seems to part of certification already…

  8. Epic claims to be very user friendly. Ask that guy who was fired from Kaiser. Why would its CEO oppose standards of usability in certification? Lack of usability wastes time and facilitates errors.

  9. All ONC HIT Policy committee meetings are recorded and made public here: http://tinyurl.com/23llupz (using tiny URL to shorten the long ONC address). Please share at which meeting and at what time during the recording did Epic’s CEO say the alleged quote.

  10. While I can’t imagine Judy Faulkner saying that, she would have been right in saying that usability should not be a factor. Usability cannot be measured & any standards used in a definition of usability would undoubtedly not be measured fairly across all vendors. Not to mention, Epic is not so bad on usability that opposing it would be extremely beneficial to them.

  11. Anonymous wrote:

    [HIT] Usability cannot be measured”

    Congratulations, schmuck; get your head out of your ass and do a little research.

    Since you’re clearly a birdbrain I’ll start you off with the book I”m using in teaching a graduate course in informatics evaluation:

    Evaluation Methods in Biomedical Informatics
    by Charles P. Friedman, Jeremy Wyatt

    Since you also appear brain damaged, here are two resources you can use to learn more about usability evaluation:


    As you seem to be new to modern technology, I leave it to you as a learning experience to find out how to access those hard-to-use tools.

  12. RE: From ExXeroid: “Re: The Hospital of Central Connecticut. The Cerner staff is down to a skeleton crew. The IT people are leaving in droves. Cerner KC is the ACS takeover, but there’s hardly anyone left to support internally after the ACS disaster.” Unverified

    Sorry for the ignorance, but what do you mean by the “ACS disaster?” I’ve been out of the loop… What happened? I’ve noticed that all the consultants, after company wide, have basically been laid off or left, but I’m not sure what happened. Thanks for any info…

  13. Wow, the quality of the discourse just dropped substantially. MIMD, if you can’t say it in a civil manner that’s a pretty good indication that what you are saying is of little value. This is not my blog — if it were you’d get a timeout just like any other elementary school child exhibiting your current behavior.

  14. MIMD: How do you expect to be a competent, effective teacher, MD, or healthcare informatics professional when you display such contempt for those who may not be blessed with your Aristotle-like IQ?

    You are probably not used to taking advice from people, but you might want to be wary of one or both of your graduate students putting a little Iocane powder in your tea before the end of the semester.

  15. Zimbu and R: Ad hominem attacks avoid the issue. There is a CEO of a IT vendor refusing to provide a user friendlky interface.

    This is all the more reason for the FDA to take charge as it is supposed to do according to Federal Law.

    Is it that Faulkner meant to say, screw usability and it will only be part of certification over many patients’ dead bodies.

    can attest that there have been many dead and maimed bodies from these products, and I would be fired if I went out side the hospital system….part of the cover up for the administrators’ partnerships with the vendors.

    The vendors are defrauding the Congress and the taxpayers.

    When you have to use these dangerously flawed products that can not be trusted because of the vendors’ failure to consider the user or the patient, you may have a better understanding of the magnitude of the riisk that patients face with these devices.

  16. I must laugh at this Kansas City report from his annual meeting: He says “The “gift” of national health care reform, plus a lot of hard work and good strategy, has put Cerner in a good place, he said. Over the coming decade, Patterson predicted, Cerner won’t just be a health care IT company; it will be a health care company.

    Read more: http://www.kansascity.com/2010/05/28/1978379/at-annual-meeting-cerners-patterson.html#ixzz0pWDW3Yvf

    First, they have to make their devices usable so that they do not kill patients and sell products based on merit rather than “deals”. What does Neal think of usability? Similar to Faulkner?

  17. How insensitive can people be? The doctor’s mother suffered irreparable brain injury because of defective HIT components and failed interfaces and you guys have the pomposity to be critical. Pardon the inquisiive expression of wonder butt are your heads so far up your anatomy that you are seeing daylight?

  18. As a former user and current developer, I’ll take my share of responsibility for the crisis in usability (or non-usability as the case may be.) I give a lot of the fault to vendors maintaining a monopoly and not opening their systems’ APIs sufficiently, and to the evolution of simple programming tools.

    Tools are getting better, Dot Net (.NET) is pretty simple to work with these days, and if more vendors will open their APIs to 3rd party developers, we may see some actual choice in the market instead of having to decide between multiple unusable systems.

    That said, I’m not holding my breath. Unless customers demand open architectures most vendors won’t be offering them. It IS the future of health care IT as I see it, and though I’m still a little lonely out here, I know I am not alone.

  19. Found the Albuquerque Presbyterian story interesting: “Re: Presbyterian Albuquerque. VMware installation caused two major network outages within 48 hours. The clinical system (McKesson) is still trying to recover: interfaces and prod down, pharmacy handhelds all needed hard booting, runaway processes triggered, unable to pull PACS studies, etc. Affected all eight facilities across the state.”

    Great that you covered this Mr. HIStalk, last week. I was away traveling through New Mexicao and read nothing of this.

    Was this reported in any newspaper or traditional media or was it covered up from widespread scrutiny with the industry promulgated line for CEOs beset by such flagrant disruptions of care: “We are not aware of any patient injury”…”due to 8 hospitals going down at once!”

    When this happens, patient care is neglected as bezillions of unprepared hospital workers scurry around like chickens with their heads cut off, while administrators check in from the country club.

  20. Re: Usability and certification.

    Usability exists, and there are fairly well-established methods for measuring it (for computer applications in general, not HIT specifically) that have been developed over decades

    It is also important, however, to acknowledge that we don’t know nearly enough as we need to about how usability of HIT applications affects the risk of error and adverse patient outcomes, and in particular, what aspects of usability are most tightly associated with those risks. This should be a major research priority, as well, of course, as establishing measures of usability that are demonstrably reliable for HIT applications.

    Regarding usability and certification, CCHIT, in the current cycle, has taken what seems to be a reasonable middle-of-the-road approach, i.e. measuring usability and reporting on the results without making usability scores a criterion for certification. Until the reliability of the usability measures being utilized (i.e. lack of variation across different testers or different instances of testing) can be established, it would seem premature to use them as make-or-break criteria for certification.

  21. RR wrote:

    “MIMD: How do you expect to be a competent, effective teacher, MD, or healthcare informatics professional when you display such contempt for those who may not be blessed with your Aristotle-like IQ?”

    As per the link cited by not tired of suzy rn above, my mother may not survive a cerebellar hemorrhage thanks to what you call “those who may not be blessed with my Aristotle-like IQ.”

    Have you no decency? Have you no kultur? Does human life mean anything to you? Are kind words more important than keeping patients safe? What kind of person are you and Zimbu, anyway?

  22. Dr. Herzenstube Says:

    “It is also important, however, to acknowledge that we don’t know nearly enough as we need to about how usability of HIT applications affects the risk of error and adverse patient outcomes”

    In a several decades old HIT industry, just why is that, exactly?

  23. and, I might add, if “we don’t know nearly enough as we need to about how usability of HIT applications affects the risk of error and adverse patient outcomes”, then why are we rolling HIT out nationally?

  24. Oh, in #25 I forgot:

    Health IT is a huge EXPERIMENT using patients and clinicians as the canaries, all for fun and profit…

  25. I am sick of the jerks that post the comments on these threads & if it continues, I probably will just stop reading.

    Now, while you can measure components that play into usability, it is very subjective & the models are ultra-simplistic (& no I don’t teach classes on usability, so I’m probably not entitled to my opinion). The effort that it would take to make it objective would likely add another trillion to the debt while the stinking government argues over the definitions of workflow and which standards to use to measure them.

    MIMD – Your(?) link does not work, you would think in all your glorious wisdom, you would understand how to link to a simple web page & then you wouldn’t need to condemn everyone for not having read it.

  26. HIT certainly has some issues. Sounds like most of the rest of us do as well. Is there a better place to start than HIT? I’m always looking for the solution to all of these crises and have pretty much decided that it’s not a silver bullet, it’s open platforms and working together and trying all together (all together now, all together now) to make it functional (in spite of the dysfunctional processes most hospitals and clinicians have fostered over the years.)

    People die in hospitals, sometimes before they should. If HIT was associated with a fatal accident, do we blame the universe of HIT? If it were a pharmacist, would be blame the universe of pharmacists?

    My point of view is that we’re trying to make it better and working together is far preferable to blaming each other for our various lessons.

  27. Microsoft and Apple have measured usability for years, as the document “Usability in Software Design” http://msdn.microsoft.com/en-us/library/ms997577.aspx clearly shows.

    That HIMSS has largely not even acknowledged a usability problem with health IT until the June 2009 document “Defining and Testing EMR Usability: Principles and Proposed Methods of EMR Usability Evaluation and Rating” (http://www.scribd.com/doc/17227201/HIMSS-EHR-Usability-Task-Force-Report-on-Defining-and-Testing-EMR-Usability) indicates a complacent and lazy industry indeed.

    From the executive summary from HIMSS:

    “Electronic medical record (EMR) adoption rates have been slower than expected in the United States, especially in comparison to other industry sectors and other developed countries. A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available.”

    That is a devastating admission. What has the industry been doing the past few decades, playing Pong?

    Stop the lies, already.

  28. Our government is so woefully inadequate to do usability testing it is an absolute joke to even consider it.

    These are the people who regulate oil drilling. They provided the response to Katrina.

    Look at what is going on with EMR certification.

    We’ll look back on what happened in these past few years and the 4 to come and be absolutely embarrassed.

    Government is run by the same people that brought you the DMV.

    There is no solution in bureaucracy. Just more wasted taxpayer money.

  29. MIMD – I think your argument would have more credibility if you would lose the sarcasm and visciousness. When you go off like that, I just tune you out.

    Okay, so healthcare IT has errors and people die. Gee, did people die BEFORE healthcare IT – were there NO medical errors when we relied on handwriting, clinician’s memories, and folks to distribute paper charts that had obsolete data by the time they were in the hands of care providers? YES – there were lots and lots of errors.

    Healthcare IT isn’t perfect yet. Never will be. But, I will take my chances with an automated, integrated system with my full, lifetime medical record easily and instantly accessible to the olden days.

    Stay in the dark ages if you want. Do you feel safer there? If so, you are naive.

    Sorry for your loss – but it doesn’t change the fact that many more errors occur WITHOUT good IT systems than with them.

    I don’t care, MIMD, if you are PC or not. But, you do not have to be profane and disrespectful of others opinions. It makes your arguments look weak and emotion-fueled.

  30. I rarely censor, but this thread has veered dangerously from usefulness to incivility. I won’t lock the comments for this post, but I will edit or delete those that don’t add value or that contain personal attacks.

  31. The VA had 40,342 total operating beds at the end of FY09. This included hospital, Nursing Home, and Domicilliary beds. Acute care inpatient beds were 19,856 at end of FY09. This is only a small part of the VA care that requires the use of CPRS and VistA however. Outpatient care makes up the largest portion of VA health care. FY09 saw over 62 million outpatient visits for about 5.3 million unique patients. Each of these visits will use some part of the VistA system.

  32. Usability, Meaningful Use, CCHIT, etc can and will continue to be discussed here, even by morons like me who had to look up “kultur” (which I definitely do not have, thank you). But bowing to the bullying, arrogance, and repeated “head-up-ass” insults beset upon those who dare dissent from the veils of “critical thinking” is a guaranteed way to go on killing the tens of thousands of hospital patients who suffer harm or death each year by the cause of preventable human errors. I am truly sorry to those who have suffered personal tragedy at the hands of our broken health system. The unfortunate truth remains however that for every catastrophe caused by broken computer system interfaces and bad HIT, there are thousands of quiet tragedies caused by bad handwriting and poor communication.

    Yes, the stakes are high here; and no, I don’t care so much for nice words or political correctness as I do for calling out a minority of smarter-than-thou types attempting to force a self-serving opinion by yelling louder.

  33. Veteran of Healthcare IT wrote:

    “Okay, so healthcare IT has errors and people die. Gee, did people die BEFORE healthcare IT”

    I should add that I’d written the CEO and Chief of Staff of the hospital where my mother was injured on my concerns about their HIT appx. one month before her current travails.

    Making excuses for easily-preventable HIT errors is itself inexcusable. If this industry is to facilitate healthcare, its attitudes about rigor need major revision.

  34. Mr. HIStalk Says:

    “I rarely censor, but this thread has veered dangerously from usefulness to incivility. I won’t lock the comments for this post, but I will edit or delete those that don’t add value or that contain personal attacks.”

    I admire the level you do tolerate.

    I am signing off this thread now, as I have a brain-injured mother with complex additional, secondary complications to attend to.

  35. MIMD: Again, condolences about the horrible tragedy with your mother. I am NOT making excuses for any person, organization, or system that has errors that go uncorrected. But, I would also ask you to consider the following:

    I worked in healthcare and healthcare IT for over 3 decades. While I certainly witnessed errors with IT systems that took too long to correct, or perhaps were never adequately addressed, I also personally experienced organizations that poorly implemented IT systems. In some cases, I felt so strongly about the poor decisions being made by the organization that I put in writing my concerns, and made all of those involved sign a document that stated they were implementing the system in a fashion that was not recommended and could have potentially serious side effects.

    I would have our lawyers create a document, and instruct the organization that they would have to have their lawyers sign off on it, and all of them put their signatures on the document. Many, many times this strategy worked to get them to understand the seriousness of their decisions – but sometimes, they forged ahead anyway and didn’t heed the warnings.

    It’s been stated out here before – but how many times have most of us witnessed an organization putting in a NEW system, only to bring foward the design decisions and processes of the OLD system. They are simply re-automating what they were already doing with a new system. It makes you wonder why they purchased a new system. Implementing these systems is HARD – harder than you could imagine if you’ve never been part of doing it.

    Sadly, MIMID – it sounds like you found a place in the processs and implementation of the system being used at your mother’s organization that could lead to serious errors and you were ignored. This isn’t a system problem, in my opinion. This is a people problem. Turning off the system and reverting to older, manual methods probably is not the answer here – rather, listening to valid concerns and creating system solutions coupled with well communicated processes and policies, – this is what should have occurred when you voiced your concerns.

    Regarding usability, it always amazes me how everyone at an organization wants alerts and warnings all through the system, EXCEPT when they are using it (because, of course, they didn’t need them). Alerts are funny things – you love them when they keep you from overlooking something or from making a mistake – you hate them when they tell you something you already know. But, how is the system to determine what you know, and what you don’t, or what you might have overlooked. There is a precious and delicate balance involved in implementing these systems, and making the wrong decision based on, many times, clinician input, can lead to an error. But, it may be the very same error that would have occurred without the system being in place.

    As someone that designed many, many IT systems for different areas of the hospital, I can tell you that one person’s idea of usability is typically at odds with the next person’s. The flow of information, for example, in completing an online order, is different in one persons thought processes versus another. This is probably why Ms. Faulkner is leary of measuring usability – it is so subjective. It is somewhat like judging art or architecture – what is beautiful (or useful) to one person, is ugly or un-useful to another.

    Trying to have an independent group judge your product’s useability is like putting the federal government in charge of something – you will ultimately have standards that are broad, whitewashed, mired in legal ramifications and which render a system utterly “unuseful”.

    The best way, IMHO, to measure usability is in user adoption. Yes, many organizations try to legislate system use – e.g. “you MUST use the system or you cannot practice here”. But, you have to ask the users a simple question – “would they rather practice medicine WITH this system, or WITHOUT it?” Any system can be improved. And, the healthcare IT companies I personally know of, toil long and hard to create systems that are highly usable AND safe. They do not always get it right. Every system has errors in it – which typically means that someone is using the system in a way that is slightly different than expected or designed (which doesn’t mean it’s a wrong way to use the system – just that it easn’t anticipated) – and so that condition fell through the testing regimes as it was never tested.

    It must all seem so easy from the outside looking in. Designing and implementing software for healthcare is one of the hardest things you can spend your time on. There is not right or wrong way to do things. And there are as many ways of doing things as their are clinicians.

    But the one thing I hope you will know – again, from someone who spent their entire career working in healthcare IT – the patient’s safety is of the UTMOST thought when working on system design. It is the MAIN CONSIDERATION, that gets discussed over and over and over. I have seen design committees, comprised of clinicians and programmers, screaming at each other in meetings over safety issues. And, do not assume that it’s only the clinicians who are fighting on the side of safety – the programmers quickly learn how their applications can be twisted and used in unsafe ways and they use that knowledge as they design newer applications.

    How to ride that balance between system intervention and usability. To to make, for example, the physician ordering process faster than writing a manual order – all the while trying to eliminate all the errors caused by writing manual orders. These things are at odds with themselves. And we all know that writing manual orders causes a huge number of errors. But, physicians will still complain that putting in electronic orders slows them down. What is the right balance?

    The other things that must CONSTANTLY occur with ANY system (be it manual or computerized), is a regular review of what is working and what is not. I have hundreds of examples where systems were implemented and poor design decisions are still in place years later when I review their current state. It is incredibly frustrating how many organizations will hold on to a bad process and never get around to changing it. Even if it is technically a simple fix like flipping a switch. It’s enough to make you pull your hair out.

    Although, to be quite honest, I’m sure that the organizations get very frustrated with IT systems that have errors that take years to fix, as well. And, the only answer I have to that problem is in how companies resource, and prioritize, system errors that are discovered. Again, in my opinion, IT companies will always put more resources on designing and selling the “next new thing” than they will in making corrections to what they’ve already put on the shelf. It’s not right – but the appetitie for new things is so voracious – it’s how these companies operate.

    It usability a question that will continue to plague us. Absolutely. But measuring usability? I still say it is highly subjective. You say tomAto, I say tomaHto.

  36. It would be nice (although difficult) to take the emotion out of these debates.

    Usability- Isn’t it in the eye of the user. Doesn’t usability depand on the user? You can take a poll to gather feedback on people’s thoughts, but you cannot scientifically measure usability and more than you can measure the “drivability” of a car????

    The skill of the driver (or user) is just as much a part of it as the device itself.

  37. @ Skeptic:

    Designing applications for listening to music, or watching videos, or using your iPhone, really isn’t at ALL the same as applications that take care of human lives, in real time. And, everything that users do in a healthcare IT application must be exchanged, real time, with other users caring for patients, as well as databases that contain reference or other content data. How that information is presented to the user, in what sequence, how many keystrokes, the flow of the data, how information is cloned from one order to another – these are ALL things that are highly subjective.

    Perhaps this is why Apple doesn’t automate hospitals and healthcare in any competitive fashion. Truely integrated, real time systems are much harder to develop than static applications.

    Microsoft has developed some usability or visual standards – and many healthcare IT companies use those visual standards. But, that doesn’t mean you can dictate usability in a healthcare setting.

    So, I respectfully disagree with Microsoft and Apple when it comes to these types of applications. Usability, in my opinion, will always be highly subjective and preference driven.

  38. Concerning all the comments on software usability.

    First, MS’s work cannot be ignored, as they reveal first principles that apply no matter where software is deployed. They specifically state at http://msdn.microsoft.com/en-us/library/ms997577.aspx :

    …Usability is about whether a person can use the product to perform the tasks they need to perform. Usability testing primarily measures performance, not preference.

    If MS is not credible, then google searches on ‘nasa software usability’, ‘NRC software usability’, ‘FAA software usability’, ‘NIST software usability’ etc. should be. There is also an extensive computer science literature on software usability.

    The health IT industry has been extremely slow to embrace the teachings of other disciplines, even when it’s really hitting them in the face (such as Dr Jon Patrick’s work at this link, PDF). This is unfortunate.

    Software usability is not ‘subjective’. It is a measurable quantity via quantitative and qualitative methods and standardized processes, to a high degree of reliability. If an industry chooses to do so.

    That it has not, and as someone else pointed out only recognizing it’s a problem with a mid-2009 HIMSS paper, is a real pity.

  39. I have learned a lot by reading these comment. Thank you Mr. HIStalk. I think I am beginning to understand why it is difficult to trust the care given by doctors and nurses who are required to use systems that have kind of put usability on a back burner.

  40. A couple things are evident from this thread: first, MIMID’s comments, while some may think immoderate,, simply reflect the anger of anyone (usually a patient or patient’s relative) who is the victim of a medical error. Where do you think the burgeoning impact of patient advocates and e-patients is coming from? We M.D.’s often look as these people as “crazies” – well, now one of our own has experienced it. So maybe they’re not crazies.

    Second, from all I’ve read on the federal HIT push and vendors’ reactions to it, it seems vendors’ motives, predictably, are simply to feed at the trough of federal dollars without an earnest effort to understand why users don’t like their product. They have yet to show me any evidence that they care, at all. Depressing stuff.

  41. I have sat in usability laboratories and watched as users were evaluated using particular applications. I have seen many good, and many not so good, changes made to the software based on the information from these usability tests. I can tell you many stories of applications that tested very highly in the laboratory for so-called usability, and out in the field, the application fell on its’ face.

    Some clinicians will achieve greater productivity with one application while still others will be more productive with a different application. Extaneous keystrokes are certainly measured and can be the easiest to eliminate. What is harder is creating applications that span multi-disciplines, with patients in various phases of diagnosis and treatment, that create higher productivity amongst disparate types of caregivers. This is why there is typically a high degree of customization and preferences to modify application behavior – which becomes MUCH harder to measure and quantify as the application itself morphs based upon those settings. This is also why there are more and more systems developed specifically for specialized disciplines.

    But, all the testing in the laboratory does not guarantee that the application will achieve great usability, likability, and adoptability out in the field, with real users caring for patients in real time.

    Just my opinion. But, I have “been there/done that”, so I’m not talking out of theory or conjecture, just real life experience.

    And, I’m not saying to not do the usability tests – but to try and standardize usability (using an “independent” legislative type body – yikes!)and make purchasing decisions based upon usability scores – well, that is where we probably part ways.

    You can measure and quantify and qualitate usability data – but with the high degree of application preference settings which modify application behavior – I’m not sure how you compare apples to apples. That is why I believe there is subjectivity involved. How an organization chooses to define thir preference settings, and define their policies and procedures, will always affect the usability of an application/system.

  42. “They have yet to show me any evidence that they care, at all.”

    What kind of evidence have you been looking for?

  43. Mr H.

    Regarding your poll “What’s the best way to encourage better EHR usability?” Might want to add one more item to the list.

    How about “HIT vendors recruit and retain more Clinicians (the actual end users) to work directly with the developers in designing their clinical systems.”

  44. “Happy Memorial Day! Except for you non-US readers, who I confess I wasn’t thinking about when I talked about the holiday last week. Thanks to the reader from Canada who reminded me…… As the programmers say, Hello World.”

    Thank you, and Hello World to you too :-).

  45. bev M.D. Says:

    A couple things are evident from this thread: first, MIMID’s comments, while some may think immoderate

    To anyone who thinks my comments “immoderate”:

    Medicine is a serious profession, and if you have such a thin skin to think strong patient advocacy “immoderate”, you do not belong anywhere near the field.

  46. Veteran of Healthcare IT Says:

    Sadly, MIMID – it sounds like you found a place in the processs and implementation of the system being used at your mother’s organization that could lead to serious errors and you were ignored. This isn’t a system problem, in my opinion. This is a people problem.

    I believe it reflected both.

    A critical medication already in the system should not “disappear” – or be allowed to made disappear w/o serious warnings to the operator and clinicians down the pipeline that a critical med was ‘recently d/c’d” or something to that effect.

    The people problem is also a pervasive issue in health IT.

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