EMR Featuritis, Usability, and Workflow: A Video

Short Link: http://j.mp/5CRUr8

Today’s trend is to add more and more EMR features. At first only the most important features are created and special attention is paid to simple and elegant usability. However, each additional feature adds less and less value, until adding features actually reduces the total value of having a EMR in the first place.

featuritis_curve

This phenomenon of feature creep or “featuritis” is well known. It is:

“the proliferation of features in a product such as computer software…Extra features go beyond the basic function of the product and so can result in baroque over-complication rather than simple, elegant design.”

and

“adding feature upon feature until the simple things you used to do are no longer simple, and the whole thing feels overwhelming…

The solution to “featuritis” is to:

Give users what they actually want, not what they say they want. And whatever you do, don’t give them new features just because your competitors have them!”

The following short three minute video illustrates the point (timed transcript below if you’d prefer to skip the video). The actual charting of a simple straight forward pediatric encounter only takes 37 seconds, from start to end. One pediatrician I know famously says “If I can’t chart a routine otitis media encounter in under 30 seconds, I know something is wrong!” (As in, the server is slow today, tell someone to fix whatever needs to be fixed.)

By the way, the comment that using a finger instead of a mouse takes only a third of the 37 observed seconds only initially seems implausible. There are 17 clicks. Can you tap your finger 17 times in 12 seconds? Certainly you can. Wait, you protest, what about tapping a finger in *different* places? Nope, can still be done in 12 seconds. Musicians do this sort of thing all the time. As noted in a previous post, the cognitive motor skills necessary for data entry in a pediatric EMR workflow system more resemble that of a piano player than a knowledge worker. (By the way, I’m planning on a future post that critiques EMR data and order entry from the point of view of psychological models of musical cognition, learning, and motor skill.)

piano_hands_keys

I’ve nothing against ten minute-plus on-line demos of every jot and tittle of what a pediatric EMR can do. Back in 2002 it took an act of congress to get an EMR demo (the basic issue was that folks resented having to register and provide lead information *before* they even got to see a demo and decide whether or not they wanted to provide their personal information). I believe that my “one click” demo of a pediatric EMR workflow system pioneered the self-running browser-hosted voice-narrated EMR demos that are now common (note the “Version 4.0.02 (10/23/2002″). (Send me a link if you know otherwise.)

What most pediatric EMRs miss is the common sense rule that the simple should be easy and the complex possible. But making the complex possible should not make the simple hard. That is the lesson of the need to avoid the downhill slope side of the EMR Featuritis Curve.

Whether for the search engine robots, for purposes of improved Web accessibility, or just for the speed readers who find videos an inefficient use of their time, here is the time-tagged, color-coded, word-for-word transcript of 37 seconds to chart a routine pediatric encounter.

Time
0:00 Let’s chart a patient!
0:03 The set up is that the nurse has already seen the patient, brought him back to the examination room, taken a chief complaint, taken vital signs, and has completed her job
0:16 I’m finishing up with the patient in exam room four, I look at my office view screen, and I notice that Tommy Smith in room one has been waiting the longest to be seen by me, that’s how I know who to go see next
0:30 I open the chart and I notice that Tommy has a sore throat and his temperature is 102 and that his strep is positive
0:39 It’s time to go see the patient
0:41 I open the door, introduce myself and start examining the patient while taking a bit more history from the mother
0:50 After examining the patient I formulate a diagnosis and treatment
0:57 Now it’s time to chart the patient
1:01 So let’s look at our watches (everyone with a second hand) let’s go ahead and start…
1:07 …NOW…
1:08 I open the chart
1:13 Chart my physical exam, my pharyngitis exam
1:19 Chose my diagnosis of strep pharyngitis
1:25 Make my treatment duracef and follow up in 3 days
1:31 Write my prescription
1:33 Edit my follow up if necessary
1:37 Have created a beautiful chart
1:42 Check my billing
1:44 And I’m finished
1:45 (Audience: Exclamations, 37 seconds! Wow!)
1:50 As you can see I did this with a mouse in 37 seconds
1:56 In reality, with a finger or a stylus you can do this in about a third the time
2:03 I know this because when I’ve looked at timed studies of our current physicians’ charting at pediatrics or family practice, the average chart for a sick visit is 28 seconds.
2:20 Not bad!
2:22 A well visit is actually around 55 seconds, there’s more to chart! Make’s sense.)
2:30 Our physicians can chart quickly, they can chart accurately, and more efficiently. The end result is that patients move through your practice much faster, creating the opportunity to see more patients, spending more time with individual patients, or going home early
2:58 Thank you!

P.S. Less is more.

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4 Comments

  1. Posted September 11, 2012 at 1:37 pm | Permalink

    Love this blog and your thoughts ! Furthest back I can find our narrated one click demo is in 2001 though Im sure it was live a few years before that.

    Can’t wait to see you next article.

    Tx

    http://web.archive.org/web/200102011952/http://www.docs.com/Products/Modules/onlinedemo.htm

  2. chuckwebster
    Posted September 12, 2012 at 2:27 pm | Permalink

    Hi Greg!

    That is an impressive collection of EMR modules. And to have them, individually, available online and viewable (and hearable) without requiring registration was indeed a landmark.

    What I mean by “ten minute-plus on-line demos of every jot and tittle of what a EMR can do” is a narrated patient encounter from beginning to end, from check-in to checkout. That’s usually what happens when a potential EMR customer asks for a demo. I may have missed it, but there an example of this on the link you sent me?

    I try to never miss an opportunity to extol workflow management systems (now business process management and case management systems) in healthcare. I won’t miss this one either. (If you read or follow me regularly, go get a cup of coffee, it’s the same ol’ same ‘ol!)

    WfMS and BPM systems have, at their heart, a workflow engine that executes process definitions. You can think of a process definition as being a “program” that a non-programmer can create and edit and improve. After this program is created it can be automatically executed by the workflow engine if its preconditions have been met. You can think of this sort of like firing a rule in an expert system or clinical decision support module. Preconditions can be almost any aspect of why the patient has come to the hospital or medical office. These conditions might include presenting description or diagnosis, such as acute chest pain or suspected myocardial infarction. Or it could be a banal as a physical necessary to go to camp. The process definition (when executed) tees up a bunch of pending tasks for various people or roles (nurse, physician, tech, etc).

    Once a process definition begins to execute, there are parameters that tweak or specialize its behavior. Depending on developmental age, different developmental tests are queued. Also, when a definition executes (is “enacted” in process-aware information system parlance) users can pause, redirect, cancel, postpone, forward individual tasks (that’s the adaptive part of the case management functionality). This is illustrated in the following (see link further below) online demo when I mention the physician jumping off the definition to do an optional something-or-other but then returning to the workflow.

    The link you sent me has a wonderful collection of EMR modules, circa 2001. Most certainly your screens look a bit different today and there are many more of them.

    But, what this blog (and Twitter account: @EHRworkflow) is about is the workflow technology to glue the right set of modules/tasks into an effective, efficient and satisfying workflow. A workflow engine and process definitions provide this glue. Additional BPM functionality provides all kinds of wonderful additional stuff, from real-time visualization of task status to process mining, simulation, and optimization. But I’ll set that aside and focus on the importance of combining modules into coherent workflows that don’t force doctors to, themselves, become the workflow engine, which they hate.

    At the end of the following check-in to check-out family medicine demo, at about 4/5ths of the way through (just after 11:10AM becomes 11:11AM) I pop open the process definition editor (in this system called the “Workplan Editor”) and explain, in more basic and simpler terms, exactly what I covered in the previous couple of paragraphs.

    http://chuckwebster.com/demos/ehr_workflow_family_medicine/ehr_workflow_family_medicine.html

    Here’s a screenshot, so you’ll know when to stop when fast-forwarding through the demo.

    workflow-editor.png

    And here’s a link to a video interview with a solo pediatrician describing how a workflow engine and process definitions work together to automate his workflows and save work for him and his staff.

    http://chuckwebster.com/2009/05/ehr-workflow/video-interview-dr-armand-gonzalzles-emr-workflow-management-in-primary-care

    Sometimes these workflow editors look more like Visio, the desktop diagramming application often used to draw workflows. The Siemens Soarian system has one of these workflow editors, based on a workflow management system developed by Staffware (now part of TIBCO).

    So, in short, I’m impressed with your high quality one-click on-line demos of individual EMR modules, as well the significance of their early and pioneering appearance on the EMR demo scene.

    But I’m after bigger game. Traditional EMRs need to move from a collection of modules, selectively executed by the user, to workflows of modules in which as much as possible happens automatically. This is the secret to dealing with the clickity-clickity-click usability problem plaguing EMR adoption today. That and speech recognition and natural language processing, but you can read more about that at the following link.

    http://chuckwebster.com/2012/08/natural-language-processing/video-interview-and-10-questions-for-nuances-dr-nick-on-clinical-language-understanding

    (By the way, workflow tech will also be useful incorporating language tech into EMR workflow.)

    The individual demos of EMR modules at the link you provide predate my demo of workflow combining a bunch of modules. But they sort of prove my larger point. Instead of viewing (executing) these modules individually, wouldn’t it be better if they happened automatically (and differently for different clinical contexts)?

    I still think my beginning-to-end every jot-and-tittle patient encounter EMR demo is the first of its kind. More importantly, it illustrates what I want to illustrate about knitting modules together in to usable EMR workflows.

    As they say on Twitter: Thanks for sharing!

    –Chuck

  3. Posted September 13, 2012 at 8:27 pm | Permalink

    Wow - Thanks for the reply. We did have a complete demo available - not just of the modules but the internet wayback machine didn’t seem to archive it. I’m with you - I remember the days when it took an act of congress to simply get a price.

    We’ve been working on workflows though our end user implementation is still in the beginning stages. In fact we express our clinical alerts as user definable workflows utilizing the Windows Workflow Engine. I agree that much more is possible and desperately needed in this industry. Tx for writing.

  4. chuckwebster
    Posted September 14, 2012 at 11:57 am | Permalink

    Kudos Greg! (and SOAPware)

    I started this blog in early 2009 to encourage and accelerate diffusion of workflow management system and business process management system technology into healthcare IT, particular EHRs.

    http://chuckwebster.com/2009/02/ehr-workflow/welcome-electronic-health-record-workflow-management-system

    Workflow engines and process definitions are signature elements of WfMS and BPMSs. So I look for mentions of workflow engines in EHRs and health IT systems. Every time I find mention of a workflow engine in an EHR or health IT context I tweet “Workflow engine sighting! …”

    So, with respect to SOAPware:

    By the way, I’ve started doing interviews with folks who I feel are bringing much needed innovation to health IT. Here’s a couple (with more in the pipeline):

    Process Mining:

    http://chuckwebster.com/2012/05/ehr-workflow/new-process-mining-tool-debuts-healthcare-opportunities-abound

    Speech Recognition and Natural Language Processing:

    http://chuckwebster.com/2012/08/natural-language-processing/video-interview-and-10-questions-for-nuances-dr-nick-on-clinical-language-understanding

    Anyway, I’d be delighted to interview a representative from SOAPware about your important move into what academics call “Process-Aware Information System” (or PAIS) technology!

    Right now, mobile-cloud-social-bigdata is the new hotness. Workflow management system and business process management system, with workflow engines executing process definitions, are joining the conceptual and technology melee beginning to shake up health IT.

    Aside from all of the practical advantages of workflow engines, I think they can play an important role in educating and marketing smart-workflow EHRs. For example, take a look at my Litmus Test for Frozen EHR Workflow.

    http://chuckwebster.com/2009/03/ehr-workflow/litmus-test-for-detecting-frozen-ehr-workflow

    How about a one-click video of a SOAPware user tweaking SOAPware workflow to their liking, without having to go back to some distant C# or Java programmer?

    Thank you for reaching out!

    Cheers

    –Chuck

One Trackback

  1. [...] (pleasantly) by the following video, which can be found embedded in an equally interesting blog post on EMR feature-creep or “featuritis” by Dr. Charles Webster.  (I would have shared the video here but it’s only available on Dr. [...]

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