Intuitive vs. Intuitable EHRs: Do We Need Smarter Users or Smarter User Interfaces?

Short Link:

  • Question: Do We Need Smarter Users or Smarter User Interfaces?
  • Answer: Smarter User Interfaces.

Pundits often call for more “intuitive” EHR and EMR user interfaces. If I may be pedantic, they probably mean “intuitable” user interfaces. Usability experts note the difference.

Peter Bagnall puts it pithily:

Naïve designers often talk of making things intuitive. What they really mean is intuitable – able to be understood through intuition. A thing can’t be intuitive unless it happens to be one of those rather rare and special things that contain a brain – like you, me or my dog. (Easy, Intuitive and Metaphor, and Other Meaningless Words, my emphasis)

And Michael Zuschlag:

“Intuitive” (technically, it should be “intuitable”) means the user can use the UI without having to consciously stop and figure the UI out. Learned habituated responses are performed without conscious thought, so intuitive includes more than instincts. (Comment on The Only “Intuitive” Interface is the Nipple. Do You Agree?, my emphasis)

And finally Jef Raskin, of Apple Macintosh fame:

One of the most common terms of praise for an interface is to say that it is “intuitive” (the word should have been “intuitable” but we will bow to convention). (Intuitive Equals Familiar, my emphasis)

I also usually bow to convention. I understand that meanings are determined by communities and usage, not dictionaries and word police. However…

Not this time. Not now. Not this post. :)

If EHRs and EMRs Only Had a Brain ♫

One of my many degrees (“many degrees” being relative, I once read the obituary of a man who collected 13 non-honorary degrees before shuffling off this mortal coil) is an MS in Intelligence Systems, a combo of artificial intelligence and cognitive science. Intelligent systems “perceive, reason, learn, and act intelligently.” That many EMRs cannot, is at the root of their relative lack of usability.

Consider the distinction between intuitable EMRs (EMRs that are “figure-outable” by their users) versus intuitive EMRs (EMRs that figure out their users and do something useful with that insight). Intuitable usability corresponds to what I call shallow usability. It’s the “surface” or skin of an EMR.

In contrast, intuitive usability (used “correctly”) corresponds to what I call deep usability. It is about how all the components and processes deep down behind the user interface actively work together, to perceive user context and intentions, reason and problem solve, and then proactively anticipate user needs and wants. Deep usability is like having the hyper-competent operating room nurse (to whom I’ve compared workflow-driven EMR user experience) handing you the right data review or order entry screen, with the right data and options, at the right moment in your workflow.

To perceive, reason, and act (let alone learn) EMRs need at least a rudimentary “brain.” When many folks think of medical artificial intelligence, they think of medical expert systems or natural language processing systems (rule-based, connectionist, or statistical). I’m a fan. I took courses. I programmed them. They have great potential, some already realized.

However, the most practical candidate “brain” today, with which to improve usability by improving workflow, is the modern process-aware (and context-aware) business process management (BPM) engine (AKA workflow or process engine). I used to give an annual three-hour tutorial called “Workflow Management Systems: Key to EHR Usability” on this topic at the old TEPR conference (I believe TEPR stood for Towards the Electronic Patient Record).


Intuitive EMRs need to represent user goals and tasks and execute a loop of event perception, reasoning, and helpful action. BPM process definitions represent goals and tasks. During definition execution, goal and task states are tracked (available to start, started, completed, postponed, cancelled, referred, executed, etc) and used to coordinate system-to-system, user-to-system, system-to-user, and user-to-user activity.

BPM engines “perceive” by reacting to not just user-initiated events, but potentially other environmental events as well, an example of complex event processing. For example, a patient entering or leaving a patient class or category, going on or off a clinical protocol or regime, moving into or out of compliance, measuring or needing to measure a clinical value, or a clinical value becoming controlled or not controlled, are all complex events that can and often should trigger automated workflow.

Process mining can analyze detailed traces of past behavior to suggest improvements to processes (BPM’s “process optimization process”), rudimentry learning if you will. BPM is even beginning to incorporate intelligent agent technology.

There is also a debate going on within the BPM and ACM (adaptive case management) communities relevant to designing EMRs that balance process-centric and human-centric EMR, EHR, and clinical groupware design. We (healthcare) need the executable process models of traditional BPM to automate and facilitate predictably routine patient care processes (including effective, efficient, and satisfactory interaction at the EMR user interface) *and* adaptive case management techniques for dealing with less predictable processes that cannot be modeled in advance.

Context-Aware, Process-Aware Intelligent EMR, EHR, and Clinical Groupware

EMRs, EHRs, and clinical groupware need context-aware intelligent user interfaces. Context-aware information systems are adaptive, responsive, proactive, and capable of autonomous action.

  • “Adaptive systems: these learn their user’s preferences and adjust accordingly….
  • Responsive systems: these anticipate the user’s needs in a changing environment.
  • Proactive systems: these are goal-oriented, capable of taking the initiative, rather than just reacting to the environment.
  • Autonomous systems: these can act independently, without human intervention.” (Predicting Context Aware Computing Performance, my emphases)

Learn, anticipate, goal-oriented, initiative, independent…none of these describe the behavior of today’s typical EMR towards its users. As a consequence physicians must compensate with a torrent of clicks (so-called “clickorrhea”) to push and pull these EMRs through what should be simple patient encounters.

Context–aware EMR user interfaces are also examples of intelligent user interfaces.

“The requirements imposed by human-computer interfaces … exceed the capabilities of conventional interfaces which often fail to reflect the semantics of its users’ tasks and problem domain properly. Intelligent user interfaces aim to cope with these serious semantic problems and help users to access information or solve complex tasks by being sensitive to a user’s knowledge, misconceptions, goals, and plans.

Main issues addressed by intelligent user interface research are the following:

  • How can interaction be made clearer and more efficient?
  • How can interfaces offer better support for their users’ tasks, plans, and goals?
  • How can information be presented more effectively?
  • How can the design and implementation of good interfaces be made easier?” (my emphases)

Clinical groupware is in the best position to become this next generation of context-aware intelligent clinical information systems. Why? Because clinical groupware is groupware. And the most sophisticated and mature groupware today is the modern workflow management system, represented by the business process management suite.

To achieve contextual usability clinical groupware needs to ask itself the same questions journalists ask themselves to write compelling and useful news reports—who, what, why, when, where, and how? Automated answers to these questions drive context-aware automatic behaviors, such as offering the right screen at the right time and place or accomplishing useful tasks in the background without need for human intervention.

What, pray tell, “drives” this anticipatory behavior? An executable process model. In older terminology, a workflow, or process, engine, executes a collection of workflow, or process, definitions, relying on user input and context (the who, what, why, when, where, and how) to select and control definition execution. If the engine encounters inputs for which there is no model, then fall back on general purpose adaptive case management techniques for tracking goals and tasks, making them visible and actionable by physician users. Traditional BPM technology automates the predictable routine. Adaptive case management supports dealing with unpredictable exceptions—the high value-added knowledge work that diagnoses and treats the complicated cases.

Usability can’t be “added” to EMRs, EHRs, or clinical groupware. It has to inform and influence the very first design decisions. And there are no more fundamental early design decisions than what paradigm to adopt and platform to use.

No matter how “intuitable,” EMRs without executable process models (necessary to perceive, reason, and act, and later systematically improve), cannot become fully active and helpful members of the patient care team. Wrong paradigm. Wrong platform.

Truly “intuitiveprocess-aware clinical groupware, on the other hand, has a brain, variously called a BPM, workflow, or process engine. This is the necessary platform for delivering context-aware intelligent user interfaces and user experience to the point of care. Right paradigm. Right platform.

In the spirit of advice from my Speech teacher about effectively and efficiently beating dead horses (”Tell them what you’re going to tell them. Tell them. Tell them what you told them.”) …

  • Question: Do We Need Smarter Users or Smarter User Interfaces?
  • Answer: Smarter User Interfaces.

P.S. Follow me on Twitter at @EHRworkflow.

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