EHR/EMR Workflow System Usability–Roots in Aviation Human Factors

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You may have noticed aviation-inspired terms, illustrations, and ideas on the High-Usability EncounterPRO EMR Workflow System website:

  • A pilot helped to design EncounterPRO’s user interface (UI). (Link)
  • EMR UI design is mimicking evolution from traditional cockpits to today’s glass cockpits. (Link)
  • The phrase EMR “rollout” derives historically from “rolling out” a new aircraft from its hanger for its first public viewing.
  • EncounterPRO’s Office View is like a radar view from an aircraft control tower, from where staff can see where everyone is and how long they’ve been waiting. (Link)
  • The illustration at the top of each fat footer sitemap is an aviation concourse. (Link)
  • Aviation human factors is an important subdiscipline within Industrial Engineering (which has many other useful applications within pediatric and primary care “production systems”).  (Link)
  • Then, of course, there is that cool helmet with an EncounterPRO screen projected on its wrap-around visor. (Link)


What if I told you that EHR/EMR workflow systems:

  • Reduce workload and difficulty of carrying out the phases of a patient encounter.
  • Relieve physicians of having to perform repetitive sequences that are unrewarding and for which human beings in their inconsistency can be at their best or their worst.
  • Endow physicians with the gratifying part of their jobs: decision making.

It would be true, but I would be paraphrasing page 176 of the Handbook of Aviation Human Factors in which it says that designers of cockpit automation hope to:

  • Reduce workload and difficulty of carrying out the phases of the flight.
  • Relieve pilots of having to perform repetitive sequences that are unrewarding and for which human beings in their inconsistency can be at their best or their worst.
  • Endow pilots with the gratifying part of their jobs: decision making.

I’ve seen many EMRs over the years, some designed by physicians, some designed by programmers, and many  designed by both. However, a physician, a programmer, *and* a pilot designed EncounterPRO—and it shows.

Aviation human factors techniques and ideas about individual and team performance have been used to improve patient safety (for example), but less so for sheer high-performance effective and efficient EMR data and order entry.  Since World War II, the aviation industry has spent millions (perhaps billions) of dollars on aviation human factors research on the design of high-usability, high-performance robust avionics and cockpit management systems. Many aspects of traditional EMR design contradict  this accumulated knowledge and experience.


As a result, an EMR Workflow System looks and works differently from any other EMR of which I am aware. While I wouldn’t want to fly a plane using EncounterPRO as cockpit management software, of the hundreds of EMRs out there it would the most suited to the task. In fact, after one presentation, representatives from an aviation software company approached us to ask if we would consider adapting EncounterPRO to serve as a cockpit management program. Given EncounterPRO’s roots we were flattered and intrigued, even if we eventually decided to continue to concentrate solely on ambulatory EMR workflow automation.

My own MS in Industrial Engineering at the University of Illinois, Champaign-Urbana involved a year in both the aviation human factors and health systems engineering programs. (This was by accident. There was a research assistantship available to work on an aviation human factors research project.) Aviation and aerospace medicine intrigued me for a while, but I decided that health care workflow was an even more target rich environment. Ironically, several years later I wrote natural language processing grammars for the Pilot’s Associate project (where I faced the truth of a popular linguistic proverb: All grammars leak.)

I had the enjoyable experience of hanging out with a sizable community of aviation human factors graduate students (both from IE and from other graduate departments such as psychology). That’s where I learned about the Fitts and Hicks laws that I discussed in the Cognitive Psychology of Pediatric EMR Usability and Workflow. I also bumped into an idea that has stuck with me since.

For each of the effects of the normal aging process–

  • vision decline,
  • hearing loss,
  • motor skill diminishment, and
  • cognitive decline

–there are a set of design principles and assistive technologies that address environmental challenges causing similar decreases in skilled performance.


Low light, or a requirement to rely on peripheral vision, can cause similar sorts of performance problems as those associated with vision decline. For example a fighter pilot must keep his or her eye on an opponent, but also monitor fuel and other system status indicators with peripheral vision. The most important displays are large, consistently placed, but do not block high-acuity foveal (central) vision. Cockpit designers often rely on alternative sensory modalities such as sound (buzzers) and touch (vibration) to not overload visual processing.


Similar to mild hearing loss, noisy environments (such as working around jet engines) also make it difficult for the listener to separate signal from noise. Compensatory design and assistive technology involve signal amplification (loud speakers), noise reduction (noise canceling headphones), and alternative sensory modalities (writing pads).

Motor Skill

Diminished motor skill results in increased time to hit a target and increased instances in which the target is missed altogether. So does moving a target and human relative to each other.  In the cockpit, turbulence, evasive maneuvers, or certain in-flight emergencies (such as I studied as a graduate student) cause relative movement between cockpit targets and pilot. Imagine trying to enter data and orders into an EMR while aboard a bucking bronco and you get the idea.  Compensating design makes switches larger and easier to hit, and offloads or postpones as many low-priority tasks as possible.

I am reminded of waiters in a busy well run lunch-time restaurant, like ambulatory pediatrics another classic high-volume, low-margin business. These waiters interact with an order entry touch screen that represents tables and order status located in a narrow passage between the kitchen and the tables. It’s there because waiters have to pass it anyway. Waiters do a “fly by” and enter orders while passing through this narrow passage. They even appear to rely on peripheral vision because they are carrying trays and dodging one another.


Restaurant Point of Sale Management Software

Waiters exhibit a Bernoulli Effect in that they speed up to increase “throughput” between the kitchen and the dining area. However, if they have an order they slow a bit to enter their ID, table, and order while passing by. If they have a large table order, they just slow down a bit more. As they approach they extend their hand, interact as they pass by, and enter the last of their data just as the touch screen passes out of reach behind them. I have seen several miscalculate and have to stop and return and finish an order, but usually they get the timing just right.

(Warning! Brief digression ahead!)

By the way, take a look at this list of restaurant point of sale software features and return on investment (slightly edited to make a point).

“BOOST PRODUCTIVITY Easy To Use Touch Screen Ordering…Accurate and fast communication from…staff to…staff…Intuitively enter orders with customized screens that reflect your…items and common customer [assessments and tasks] Reduce training time for new…staff.

MAXIMIZE [EXAM ROOM] TURNS: Fast Payment Processing…Eliminate manual calculations and multiple entries.

IMPROVE CUSTOMER SERVICE Valuable Time Management…Real-time [patient] status information…Effectively manage [patients] in multiple rooms…Reduce waiting time for customers.

INCREASE PROFITS Efficient Back Office Management…Detailed revenue and productivity reports…Efficiently manage staff with automatic labor costing, scheduling and attendance…Decrease routine management tasks.”


According to the National Restaurant Association’s Restaurant Industry Operations Report 2002, the average restaurant spent a total of 35% of their annual sales on salaries, wages, and benefits. Labor costs are the highest expense. Restaurant automation integrates key business functions in order to maximize efficiency and reduce labor costs.

Most restaurants operate on low profit margins. In fact, the average restaurant keeps less than a nickel in profit for every dollar earned. Furthermore, the restaurant industry has seen modest growth of 1% to 3% annually since 1991. Low profit margins combined with modest growth result in numerous challenges. Restaurant automation offers opportunities to increase revenue and sales per customer.

Sound familiar? While previously touched on, the analogy between running a restaurant and busy pediatric or primary care practice deserves  a future post.

(End of digression.)


Senior Friendly = Everyone Friendly = Pediatrician (and Primary Care) Friendly.

Many senior-friendly environments feature “Where was I?” strategically placed memory cues. Similarly, everyone-friendly technology helps us all manage tasks and remind us of what we were doing next. High cognitive load plus high mental effort plus unpredictable arrival of competing tasks plus further distractions equals forgetfulness.  Folks fortunate enough to be at the peak of their mental powers just take a bit more environmental duress to cause them to make the same sorts of mistakes that we all make when we get older.

If you’ve read any of my previous posts I suspect you know where I am going with this. EMR workflow systems show how principles of senior friendliness can result in an EMR that is friendly to anyone operating under less than optimal conditions.

Peripheral Vision

Ideally, a primary care physician (or most physicians dealing with a conscious patient for that matter) should be able to chart data and orders while giving a patient his or her full attention. Consider this quote from What Makes a Great Pediatric EHR to see what I mean:

“One Georgia pediatrician, a winner of the HIMSS Davies Ambulatory Care Award of Excellence for his use of the EncounterPRO EHR, shows his attentiveness using one hand to steady an energetic child and the other hand to enter data and orders out of the corner of his eye, facilitated by large colorful buttons. A workflow engine pushes screens in preprogrammed sequences so he is not distracted by screen-to-screen navigation. His focus remains uninterrupted and attentive to the concerned parent.”

Noise Reduction and Compensation

Pediatric and primary care offices are noisy environments, so instead of having to walk or shout down the hall, tasks automatically forward from user-to-user (consistent with executing process definitions). This compensates for a noisy environment through noise reduction (less conversation about what to do next) and use of alternative sensory modality (sight instead of hearing).

Motor Skill and Cognition

According to this video, a pediatrician can chart a routine encounter in as little as 12 seconds with EncounterPRO EMR Workflow System. What if they’re interrupted? Not only can a pediatrician quickly chart, if they’re interrupted in the midst of charting an encounter, EncounterPRO provides visual memory cues (via the Office View) to help them to later find and complete the encounter.

If a pediatrician or primary care provider must temporarily step away to perform a higher priority task, they:

  • Touch the “I’ll be back” button and the workflow engine suspends its automated workflow. Colorful information-packed bars represent this suspended workflow in the Office View’s exam rooms.
  • Do something else.
  • Later, notice an Office View service bar in their assigned color.
  • Walk to the indicated exam room.
  • Touch the colored bar (task screen appears).
  • Quickly perform the task by tapping the small number of consistently placed and (sequentially) presented large buttons.
  • Dismiss the screen.
  • Another screen appears if there is another step in the workflow that falls within their responsibility.
  • Eventually perform the final task in the workflow for which they are responsible.
  • Notice another task in the Office View for which they are responsible.
  • Leave to perform that task.

Everyone in the office participates in this basic loop of viewing a set of tasks waiting for them, choosing a high priority task (often the oldest in indicated minutes), and just doing it. There’s an interesting peer pressure effect too. No one sits down while there are tasks in their color visible to others!

While I am not suggesting that a physician can or should literally (as in the case of the previously discussed waiters) chart “on the run.” However, the ability to quickly spot what needs to be done, dash to the right patient, quickly assume and complete their portion of the encounter workflow, and move on in a few seconds is almost that.


Similar to an under-attack fighter, a busy airport control tower, or a hectic lunchtime restaurant, medical practices can be high cognitive load environments (especially during the flu season). All three require multitasking and prioritization in the face of interruption and distraction.

That’s the connection between aviation human factors and an EHR/EMR workflow system’s unusual interface. You probably weren’t expecting a side trip through senior-friendly product design (although I did touch on precisely this topic in my previous post on the Cognitive Psychology of EMR Usability and Workflow). The high-usability EHR/EMR workflow system relies on the same principles that help seniors, jet pilots, and physicians cope with noise, motion, and distraction while focusing on what is most important.

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  1. Posted September 4, 2009 at 6:18 pm | Permalink


    I spent quite a bit of time putting together an article on Pediatric EMR Workflow. It can be found here:

    Obviously, however, you are the expert. Congratulations on a very well analyzed subject.


  2. chuckwebster
    Posted September 4, 2009 at 8:03 pm | Permalink


    Thank you for visiting and for your kind comment.

    You’ve compiled a nice list of pediatric templates there.

    I’ve been meaning to thank you for posting our 2007 article What Makes a Great Pediatric EHR? to your blog last year and adding a link to (and thank you for the resulting traffic!).

    I’m pleased we could play a part in the specialty-specific EMR/EHR series that we discussed (I think we were the first that you published).

    How about an invited article on EMR/EHR Business Process Management? It’s the future.


    PS Have added a link to EHR Scope Magazine to my blog sidebar.

  3. Posted September 9, 2009 at 7:57 am | Permalink

    While the practice of primary care medicine is in many ways unique, it is also in many ways similar to other work environments. Stress is stress and routine tasks are routine tasks. Coordinating the efforts of a team is hard to do in almost any situation and making sure all team members are “on the same page” is a consistent challenge. Providing each team member with a single source of information that allows them to appropriately prioritize their own activities based on an understanding of the entire situation is always helpful.

    Being able to look at work done in other areas that have similar impacts on human performance is helpful in creating design criteria for primary care EMR’s. As Dr. Webster points out, there is compelling information from other industries that documents how human performance is impacted by high stress situations and the factors that go into contributing to stress levels.

    We in the EMR industry would be less than diligent if we did not review this literature and take advantage of the insights it provides. As I have said in previous posts, my interest is more in actual case histories from real practices than in academic studies trying laudably to reach “pure” conclusions. The real beauty is the fact that what the academic theories predict will be true, is actually true in real life situations.

    EMR’s designed around the principles of workflow management and human usability help physicians perform at higher levels and facilitated better returns on investment. I am proud to be associated with a company that is taking the time and expending the effort to explore other industries and situations to find what factors can improve human-computer interaction. The medical industry needs to be able to take advantage of what computers have to offer. Studying the human-computer interface and what affects the quality of the interactions between humans and computers in other situations can do nothing but help.

  4. chuckwebster
    Posted September 9, 2009 at 11:30 am | Permalink

    “There is nothing so practical as a good theory”

    Kurt Lewin

    Page 3 of Alexander’s Approaches to Planning: Introducing Current Planning Theories, Concepts and Issues


    Practice, in turn should be informed by theory. Practice needs theory not only to structure the world and the environment, which are objects of actions, but also to explain their actions to the actors themselves. This kind of action has been called praxis, from the Greek word for practice, which as used by Aristotle, later came to denote a certain kind of practice.

    Practice in the Aristotelian sense applies to disciplines and activities demanding more than simple technical skill needed for producing artifacts–activities affecting people’s social and political lives and their broader environment.

    ‘The end…of the practical disciplines or praxis is not theoretical knowledge…[it] is to change our forms of activity and bring them into closer approximation to the full ideal of free human activity.’”

    [my emphasis in bold]

    The EncounterPRO Pediatric (and Primary Care) EMR Workflow System has a lot of excellent research-based theory behind it. Combined with our EncounterPRO Rollout & Go-Live SYSTEM (Saves You Substantial Time, Effort, and Money) EncounterPRO really is a “transformative practice, professional, and personal experience” (as we proudly state at the top of our home page).


  5. chuckwebster
    Posted October 27, 2009 at 2:49 pm | Permalink

    I have some posts on the relevance of aviation human factors to EMR workflow and usability on this blog. This upcoming presentation looks so interesting that I’m posting this information as a comment to each of my aviation-related posts. I won’t be able to make the presentation, but would love to hear from anyone who does.



    Leadership Summit on Project and Portfolio Management for Health

    12/03/2009 - 12/04/2009

    Boston Park Plaza Hotel

    Boston, MA

    OUTSIDE INDUSTRY: Analyzing the Success of the Aviation Industry’s Implementation of Crew Resource Management

    With tens of thousands of daily flights in the U.S., airline flight crews make millions of life-sustaining decisions every day. Crew Resource Management has opened the lines of communication, leveled the hierarchy, standardized operating procedures, and engaged the entire organization in the airline safety equation. As a result there have been zero fatalities on major carriers in the U.S. since 2001.

    Acquire practical knowledge of effective interaction within high performance teams.

    Explore an interactive model of six risk-management skills.

    Team Building
    Workload Management
    Decision Making
    Situational Awareness

    Apply those skills to situations outside the airline industry.

    Captain Art Samson
    Delta Air Lines (Retired);
    Author, The Captains’ Airline; Cruising Toward Disaster

    Art Samson spent thirty five years as a professional aviator, trainer, and evaluator in both military and airline environments. At Delta Air Lines he was instrumental in developing and delivering Crew Resource Management training to ten thousand pilots and eighteen thousand flight attendants. During the twenty years such training has been provided, accident rates have plummeted and fatalities attributable to the airline have fallen to zero.

    Samson parlayed a leadership scholarship into an English degree at Lewis and Clark College in Oregon. While there, he captained the swimming team and powered them to consecutive conference championships before graduating in 1968. He became a Naval Aviator in 1970 and immediately returned to Pensacola, Florida as a flight instructor. Later he commanded countless sensitive reconnaissance missions throughout the Pacific and Indian oceans before commencing his airline career in 1977.

    As an airline pilot, Captain Samson served as a check airman and director of Delta’s Pilot Instructor School in Salt Lake City. While there he completed a Master of Professional Communication degree at Westminster College. He created and taught an Aviation Human Factors curriculum at the college.

    Art now resides in Bend, Oregon where he writes, consults, and lectures. His first novel, The Captains’ Airline, will be published late in 2009.

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