Efficient and Moral Market-driven EMR and EHR Usability Innovation

Short Link: http://ehr.bz/k0

A.S. I publish this on Thanksgiving Day and give thanks for our American tradition of innovation. It is a unique product of personality (forebearers and forerunners), platform (laws and traditions,) and opportunity (Thanksgiving’s Land of Plenty).

“There is a dream dreamed by engineers and designers everywhere that they will someday be put in charge, and that their rigorous vision for the world will finally overcome the mediocrity around them once and for all. Resist this idea - the world does not work that way, and the dream of centralized control is only pleasant for the dreamer.” (Clay Shirky, An Open Letter to Jacob Nielsen)

As a graduate student in Industrial Engineering, studying aviation human factors and health systems engineering at the University of Illinois, I would have felt personally insulted by the above quote. Now that I’ve grown up, not so much.

Twelve years ago Clay Shirky wrote a remarkable open letter to a senior spokesman and advocate for Web usability, Jacob Nielsen, in defense of market-driven improvements of Web usability over centralized enforcement of usability standards. His remarks apply remarkably well to one side of the EMR / EHR usability certification debate. In the fine spirit of Shirky’s philosophies of open source and evolvable systems I’ve adapted his letter to the EMR/EHR usability standards debate.

(By the way, I don’t know if Nielsen still agrees with himself (heck, in the words of Marshall McLuhan, even “I don’t necessarily agree with everything I say.”). I certainly agree with Nielsen about big targets, less-is-more functionality, and screen flow that matches task flow.)

In some instances the Shirky quote is close to word for word, except the substitution of “EMR / EHR” for “website” or “EMR / EHR industry” for “the Web”, and in others I more liberally adapt the quote to current EMR / EHR industry circumstances. Quotes and paraphrases are blue and indented; my comments are black and unindented.

For maximum impact you might just read the indented blue material straight through, skipping over my comments until later.

Flame on!

An Open Letter about Enforcing EMR / EHR Usability Standards

Let me preface all of this by noting what we agree on:

  • the EMR / EHR industry is host to some hideous dreck;
  • things would be better for users if EMR / EHR designers made usability more of a priority;
  • and there are some basics of interface usability that one violates at one’s peril.

So far, so good!

Where we disagree, however, is on both attitude and method - for you, every EMR / EHR is a piece of software first and foremost, and therefore in need of a uniform set of UI conventions, while for me, a EMR / EHR function is something only determined by its designers and users - function is as function does. I think it presumptuous to force a third party into that equation, no matter how much more “efficient” that would make things.

Depending on which side you’re on in the EMR / EHR usability standards debate, you may agree or disagree with this sentiment. However, it’s a close approximation of how some EMR / EHR developers feel.

What about patients, payers, public health agencies and clinical outcomes researchers? Don’t they have a stake? Yes they do: as users (and, in some cases, designers).

You despair of any systemic fix for poor EMR / EHR usability and so want some sort of enforcement mechanism for external usability standards….I believe that a market for quality is in fact the correct solution for creating steady improvements in EMR / EHR usability.

Let me quickly address the least interesting objection to your idea: it is unworkable. Your plan requires both centralization and force of a sort it is impossible to achieve. You say

“…to ensure interaction consistency across all EMRs / EHRs it will be necessary to promote a single set of design conventions.”


“…the main problem lies in getting EMR / EHR vendors to actually obey any usability rules.”

…I am relieved that there is no authority who can make EMR / EHR designers “obey” anything other than data interoperability….With the EMR / EHR use poised to go from 10-30 percent (depending on your definition of an EMR / EHR) to close to 100 percent in the next few years…the idea of enforcing usability rules will never get past the “thought experiment” stage.

The analogy breaks down a bit here. Government-enforced EMR/EHR usability standards may indeed get past the thought experiment stage.

…I want to address why I think enforced EMR / EHR conformity to EMR / EHR usability standards is wrong, even in theory. My objections break out into three rough categories: creating a market for EMR / EHR usability is better than centrally enforced EMR / EHR usability standards for reasons of

  • efficiency,
  • innovation, and
  • morality.


..The “Enforce EMR / EHR Usability Standards” Solution - redesign EMRs / EHRs not presently complying with a single set of usability conventions - takes care of 100% of the problem, while the “Create a Market for Usable EMRs / EHRs” Solution, let’s call it evolutionary progress for a highly usable EMRs / EHRs, well what could that possibly get you?

…a surprising amount, actually, if it’s properly arranged.

By ignoring the mass of EMRs / EHRs with just a few customers each and instead concentrating on making the popular EMRs / EHRs more usable and the usable EMRs / EHRs more popular, a market for quality is a more efficient way of improving EMR / EHR usability than trying to raise quality across the board without regard to user interest.

In other words, instead of raising average usability of all EMRs / EHRs, raise the usability of the most usable EMRs / EHRs through market-based innovation.


A market for EMR / EHR usability is better for fostering innovation. Good tools let EMR /EHR designers do stupid things. This saves overhead on the design of the tools, since they only need to concern themselves with structural validity, and can avoid building to complex usability guidelines….

Consider the use of HTML headers and tables as layout tools. When these practices appeared, in 1994 and 1995 respectively, they infuriated partisans of the SGML ‘descriptive language’ camp who insisted that HTML documents should contain only semantic descriptions and remain absolutely mute about layout. This in turn led to white-hot flame fests about how HTML ’should’ and ’shouldn’t’ be used.

I recall these flame fest’s well. During the early 90’s I was part of a team of developers who created one of the first clinical browsers based on SGML. (A Tcl/Tk Based Graphical Interface to Medical and Administrative Information, presented at the 1994 18th Annual Symposia on Computer Applications in Medical Care)

It seems obvious from the hindsight of 1999, but it is worth repeating: Everyone who argued that HTML shouldn’t be used as a layout language was wrong. The narrowly correct answer, that SGML was designed as a semantic language, lost out to the need of designers to work visually, and they were able to override partisan notions of correctness to get there. The wrong answer from a standards point of view was nevertheless the right thing to do.

Remember the competition between networking standards and which one won? TCP-IP did, even though it was not deemed the most elegantly or correctly designed networking standard at the time. The market will do what the market will do.

Enforcing any set of rules limits the universe of possibilities, no matter how well intentioned or universal those rules seem. Rules which raise the average quality by limiting the worst excesses risk ruling out the most innovative experiments as well by insisting on a set of givens. Letting the market separate good from bad leaves the door open to these innovations.



This is the most serious objection to your suggestion that standards of EMR / EHR usability should be enforced. An EMR / EHR is an implicit contract between two and only two parties - designer and user. No one - not you, not Don Norman, not anyone, has any right to enter into that contract without being invited in, no matter how valuable you think your contribution might be.

Here is where the analogy between 1999’s consumer-facing website and todays EMR / EHR industry is, perhaps, but only perhaps, the weakest. What about patients, payors, public health agencies and clinical outcome researchers? Don’t they have a right to interfere in the contract between EMR / EHR user and EMR / EHR user because they are directly or indirectly affected, or in the name of public good? Perhaps.

On the other hand, these stakeholders are users with their own contracts with the EMR / EHR developer. I think one especially important role for the EMR / EHR usability engineer is to help create, and then enforce, the winningest set of user-designer contracts possible. However, while I think we can agree on this, it doesn’t shed much light on the government-needs-to-enforce-EMR-EHR usability-guidelines debate. Usability engineers on one side of the debate will favor one set of contracts while those on the other side of the debate will favor a different set.

By the way, I’ve met Donald Norman, and read and reread his books. I especially recommend Things that Make You Smart.


I believe that the EMR/EHR industry can be a market for quality -

  • if switching costs can be lowered,
  • word of mouth effects made large and swift, and
  • redesign relatively painless.

If I design a usable EMR / EHR, I will get more repeat business than if I don’t. If my competitor launches a more usable EMR / EHR, it’s only a data export/data import away. No one who has seen the development of Barnes and Noble and Amazon or Travelocity and Expedia can doubt that competition helps keep sites focussed on improving usability. Nevertheless, as I am a man of action and not just a theorist, I am going to suggest a practical way to improve the workings of this market for usability - lets call it usable-emr-ehr.lycos.com.

This paragraph is, I think, key. The reason that some feel we need to “resort” to enforced EMR / EHR usability standards is because of a perceived market failure (not a uniform perception by the way). One byproduct of increased data interoperability (admittedly facilitated by government promulgated data standards) will make it easier and easier to switch between EMRs/EHRs. And as more and more EMRs / EHRs become web-based, there is less infrastructural lock-in too.

Word of mouth among physicians and along physician social networks is a powerful potential propellant (and deterrent) of EHR / EHR adoption. If switching costs can be lowered, harness this.

I am particularly interested in the phrase “redesign relatively painless,” because the Achilles heel of EMR / EHR usability has been frozen workflows that are expensive to change and which frustrate users. Most of the over one hundred posts on this blog are about technologies such as workflow management systems and business process management suites that could be used to address the problem of frozen EMR / EHR workflow.


  • reduce the cost of switching between EMRs / EHRs,
  • rely on physician word of mouth and social media, and
  • increase EMR / EHR flexibility of redesign (especially regarding workflow),

and the need for enforced EMR /EHR usability standards (and the unintended consequences) will diminish.

By the way, at CMU I took an artificial intelligence course from Michael “Fuzzy” Mauldin, Ph.D., before he founded Lycos. (Hi Fuzzy!)

The way to allocate resources efficiently in a market with many sellers (EMR/EHR vendors) and many buyers (users) is competition, not standards. Other things being equal, users will prefer a more usable EMR / EHR over its less usable competition. Meanwhile, EMR / EHR vendors prefer more EMR/EHR business to less, and more repeat EMR / EHR customers to fewer.

Econ 101 anyone? Actually, Production Possibility Frontier, but: “Production Possibility Frontier anyone?” :(

Imagine a search engine that weighted EMR / EHR usability in its rankings, where users knew that a good way to find a usable EMR / EHR was by checking the “Weight Results by EMR / EHR Usability” box and owners knew that an EMR / EHR could rise in the list by offering a good user experience. In this environment, the premium for good EMR / EHR UI would align the interests of buyers and sellers around increasing quality. There is no Commissar of EMR / EHR Design here, no Bureau of EMR / EHR Usability Standards, just an implicit and ongoing compact between users and designers that improvement will be rewarded.

When I first read this suggestion about usability-weighted search engine results, I was skeptical. But the more I thought about it the less skeptical I became.

I’ve read that Google sorts web pages using over 200 criteria and that they constantly tweak these criteria. I pay close attention to this sort of thing because I pay attention to where this blog ranks for certain phrases (“EMR + workflow”). I believe Google does in fact take into account website usability in its ranking system, that certain usability heuristics, those that can be search engine spider mechanized, do in fact give more usable websites a boost in their search ranking. At the very least, Google’s PageRank website link voting algorithm must reflect some aspects of website usability. All other things remaining equal, websites are more likely to link to more usable websites then less usable websites, and this should affect SERP (search engine result pages/position) via Google’s PageRank algorithm.

Of course, EMRs/EHRs are not websites, indexed in search engines, cross-linked so a PageRank-style Usability-Rank voting algorithm can rank them. Nonetheless, there is an interesting germ of an idea here. More later.

The same effect could be created in other ways - a Nielsen/Norman “Seal of Approval”, a “Usability” category at the various EMR / EHR awards ceremonies, a “Usable EMR / EHR Web Ring”. As anyone who has seen “Hamster Dance” or an emailed list of office jokes can tell you, the net is the most efficient medium the world has ever known for turning user preference into widespread awareness. Improving the market for quality simply harnesses that effect.

Ha! Remember web rings! The “Hamster Dance”? (wiki) I also like the idea of industry awards for EMR / EHR usability. (A self-serving disclaimer, I helped three medical practices win the first three consecutive HIMSS Davies Awards for ambulatory excellence. The submitted applications–accessible from previous link–include commentary about EMR / EHR usability.)

Web environments like usable-emr-ehr.lycos.com, with all parties maximizing preferences, will be more efficient and less innovation-dampening than the centralized control which would be necessary to enforce a single set of EMR / EHR usability standards. Furthermore, the virtues of such a decentralized system mirrors the virtues of the Internet itself rather than fighting them. I once did a usability analysis on an EMR / EHR which had fairly ugly but a good UI nevertheless. When I queried the EMR /EHR vendor about his design process, he said “I didn’t know anything when I started out, so I just built and EMR / EHR with an email link on every screen, and my customers would mail me suggestions.”

Open source EMRs / EHRs have not yet played much of a role in the EMR / EHR usability debate, or in usability in general (I love Ubuntu, but Windows 7 and Apple OSX provide better user experiences for the less technical minded). On the other hand, open source software has the advantage of a tight loop of interaction between user and programmer (à la EMR / EHR users emailing suggestions via links on EMR / EHR screens). Perhaps there is an opportunity here for open source EMRs / EHRs to exploit this potential advantage.

There is a dream dreamed by EMR / EHR usability engineers and EMR / EHR user experience designers everywhere that they will someday be put in charge, and that their rigorous vision for the EMR / EHR world will finally overcome the mediocrity around them once and for all. Resist this idea - the world does not work that way, and the dream of centralized control is only pleasant for the dreamer. The Internet’s ability to be adapted slowly, imperfectly, and in many conflicting directions all at once is precisely what makes it so powerful (would that EMRs and EHRs emulate this!), and the Web has taken those advantages and opened them up to people who don’t know source code from bar code by creating a simple interface design language (something EMRs and EHRs could use too!).

“[O]pened them up to people who don’t know source code from bar code by creating a simple interface design language”, in the long run, this is what needs to happen to the relationship between EMR / EHR users and EMR / EHR designers–they need to become one and the same. The key to this is user-customizable workflow. (But don’t get me started here, if you are interested you can read about it here, here, and here.) The EMR / EHR ecosystem needs to become more similar to the Web ecosystem. In which case the analogy between Web usability and EMR / EHR usability becomes even stronger.

The obvious short term effect of this has been the creation of an ocean of bad EMR / EHR design, but the long term effects will be different - over time bad EMR / EHRs die and good EMRs / EHRs get better, so while those short-term advantages seem tempting, we would do well to remember that there is rarely any profit in betting against the power of the marketplace in the long haul.

I couldn’t have said it better myself! (Wait a minute, I just did! In an open source, evolvable, attributed sort of way.)


The biggest difference between Shirky’s 1999 websites and today’s EMRs / EHRs is potential impact of EMR / EHR-induced medical error on patient safety. If someone can’t find their way around Amazon or Orbitz, so what. If a physician cannot find his or her way around an EMR / EHR, a critical piece of missing patient information might result in disaster for that patient. Narrowly focusing EMR / EHR usability on patient safety concerns–publishing suggested formats, an EMR / EHR incident database, educating EMR / EHR users about EMR / EHR usability–are good ideas.

However, keep in mind that standards always reduce innovation…somewhere…in hope of increasing innovation elsewhere. Draconian enforcement of EMR / EHR usability standards may increase EMR / EHR usability in the short run, but decrease the EMR / EHR usability (including patient safety) in the long run.

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

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  1. don
    Posted November 25, 2011 at 8:51 am | Permalink

    Somewhere between laissez faire and some central, governmental authority dictating how every EMR screen will look are requirements for developers to demonstrate that their EMRs are free from critical use errors of the type that will kill people.

    This risk-based approach has worked well for medical devices (among other industries) and should be applied immediately and made publicly available.

  2. chuckwebster
    Posted November 25, 2011 at 9:17 am | Permalink

    Thank you!

    Process-aware EMR & EHR technologies (which this blog is about) such as process mining–discovery, conformance (especially!) and enhancement–can and should play a role in your suggested scenario.

    Happy Thanksgiving!


  3. Posted September 21, 2012 at 6:56 am | Permalink


    Digital Health-Care Records: the Right Prescription? — Letters to the Editor - WSJ.com http://online.wsj.com/article/SB10000872396390444165804578006262470116882.html?KEYWORDS=Letters+editor

  4. Posted February 21, 2013 at 1:04 am | Permalink

    Hi back, Chuck!

  5. chuckwebster
    Posted February 21, 2013 at 7:07 am | Permalink

    Hi Fuzzy! You were a great teach.

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