User-Centered EHR Design Considered Harmful (Try Process-Centered Instead)

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Credited father of user- or human-centered system design (variously HCD, UCD, HCSD, or HCD), Donald Norman (DN) wrote a contrarian essay in 2005 (“Human-centered Design Considered Harmful”) offering an alternative vision of usability and design he called “activity-centered design.” Business process management (BPM) and workflow management systems presuppose activity-centered perspectives. I’ve argued that EHRs and HIT usability will benefit from these ideas and technologies. So I’ve titled this essay, User-Centered EHR Design Considered Harmful (Try Process-Centered Instead).

EHR car and WfMS car colliding
Welcome! (EHR + WfMS = EHR WfMS)
(from first post on this blog on 2/9/09)

For an overview of user-centered EHR design, skim my annotated tweets from NIST’s workshop on EHR usability. Dive into UCD’s original 1986 opus “User-Centered System Design” (the initials for which also stand for University of California at San Diego, DN’s then academic home). But I also recommend “Design for Success: A Human-Centered Approach to Designing Successful Products and Systems” by William Rouse (my adviser during a graduate degree in Industrial Engineering).

DN starts out:

“Human-centered design has become such a dominant theme in design that it is now accepted by interface and application designers automatically, without thought, let alone criticism. That’s a dangerous state—when things are treated as accepted wisdom. The purpose of this essay is to provoke thought, discussion, and reconsideration of some of the fundamental principles of human-centered design. These principles, I suggest, can be helpful, misleading, or wrong. At times, they might even be harmful. Activity-centered design might be superior.”

Health IT tends to be behind the curve of what’s hot and what’s not in other industries. Seven years later human/user-centered EHR design is a hot topic in health IT. It promises, supporters say, to solve slow EHR adoption by making EHRs more usable. However, I argue, activity-, or process-centered, work-centered, EHR design might be superior.

What are “activities”?

“To me, an activity is a coordinated, integrated set of tasks….One activity, many tasks.”

To me too.

“Consider the dynamic nature of applications, where any task requires a sequence of operations, and activities can comprise multiple, overlapping tasks. Here is where the difference in focus becomes evident, and where the weakness of the focus on the users shows up … The methods of HCD seem centered around static understanding of each set of controls, each screen on an electronic display. But as a result, the sequential operations of activities are often ill-supported.”

DN makes the same observation I’ve made about most EHRs. Optimization around a user, or user screen, risks the ultimate systems engineering sin: suboptimization. Individual EHR user screens are routinely optimized at the expense of total EHR system workflow usability.

“Note that the importance of support for sequences is still deeply understood within industrial engineering and human factors and ergonomics communities. Somehow, it seems less prevalent within the human-computer interaction community.”

I’ve seen EHR screens, which, considered individually, are jewel-like in appearance and cognitive science-savvy in design philosophy, but do not work together well. In contrast, industrial engineers start with understanding and modeling and optimizing interleaved and interacting sequences of task accomplishment. Information systems that can represent collections of task accomplishment include workflow management systems, business process management, case management and process-aware information systems.

“software gets more complex and less understandable with each revision. Activity-centered philosophy tends to guard against this error because the focus is upon the activity, not the human. As a result, there is a cohesive, well-articulated design model. If a user suggestion fails to fit within this design model, it should be discarded.”

Many EHRs suffer from “featuritis,” Simple elegant EHRs with simple elegant workflows are rare due to lack of cohesive, well-articulated design models; customers naively valuing quantity of features over quality of design; and regulatory requirements and penalties. (As my wife says: “There’s plenty of blame cake for everyone!”)

“Human-centered design does guarantee good products. It can lead to clear improvements of bad ones. Moreover, good human-centered design will avoid failures. It will ensure that products do work, that people can use them. But is good design the goal? Many of us wish for great design. Great design, I contend, comes from breaking the rules, by ignoring the generally accepted practices, by pushing forward with a clear concept of the end result, no matter what.”

User-centered EHR design does help get to good EHRs. Good enough isn’t good enough. If EHRs and HIT are going to help transform healthcare they need to be better than world-class (compared to what?). They need to be stellar. Traditional user-centered design isn’t going to get us there. We need to open the doors to cantankerous genius, like Steve Jobs, not afraid to break a few rules (or heads). And we need to move from user-centered to process-centered EHR design.

What about patient safety? Hard to argue with government certification and regulation, right? Public health and welfare is a traditional focus of government intervention. Instead of focusing on happy physicians happily adopting EHRs, user-centered EHR design has pivoted toward politically hard-to-argue-with prevention of medical error. User-centered myopic design takes its lumps there as well.

“[In] safety-critical applications, a deep knowledge of the activity is fundamental. Safety is usually a complex system issue, and without deep understanding of all that is involved, the design is apt to be faulty.”

Where might this insight lead? Forgive me for free associating: Safety. Error. Safe systems. Safety engineering. Reliability engineering. Systems engineering. How do all the EHR parts work together? How do all the screens work together? How do all the users work together? Workflow. Workflow technology. EHR workflow systems. True EHR workflow management systems, built with BPM technology. Fun! Thanks!

DN sums up “our” position nicely.

“The focus upon the human may be misguided. A focus on the activities rather than the people might bring benefits. Moreover, substituting activity-centered for human-centered design does not mean discarding all that we have learned. Activities involve people, and so any system that supports the activities must of necessity support the people who perform them. We can build upon our prior knowledge and experience, both from within the field of HCD, but also from industrial engineering and ergonomics.”

Substituting activity-, or process-, centered for human-, or user, -centered EHR design does not mean discarding user-centered design’s insights. Some user-centered EHR design verges on activity-centered design. 1986’s User-Centered System Design contains seminal insights relevant to activity-based design. Much of traditional user-centered design fits usefully into a larger activity-centered framework. Don’t throw it out like the proverbial baby, just let it grow up and be all it can be (to mix a simile with a slogan).

For example, I often distinguish between structured EHR documents and structured EHR workflows.

“[User-centered EHR design] deserve[s] a more instrumented and malleable EHR substrate than current EHRs typically provide….Structured-document-based EHRs and EMRs have relatively frozen workflows. They have no means to use workflow execution context (’enactment’ in BPM parlance) to decide intelligently at run-time what and how to paint content on each screen, and which screens to present in which order based on user who-what-why-when-where-how context. Structured-workflow-based EMRs and EHRs have exactly this means. Combining this means with traditional usability engineering methods promises more systematically improvable EMR and EHR workflow and therefore EMR and EHR usability.” Comment: Usability Expert Jakob Nielsen Would Like EMRs / EHRs with Big Targets, Less Functionality and Better Workflow Management

I couldn’t have said it better myself!

You may be excused if you wonder if activity-centered design and BPM are really related. And, do other people agree with Donald Norman? Yes, on both accounts.

For example:

“Most of today’s approaches to business process engineering (also called business process management) start from an activity-centered perspective. They describe activities to be carried out within a business process and their relationships, but they usually pay little attention to the objects manipulated within processes.” Business Process Modeling and Workflow Management

Not paying attention to objects manipulated within a process is useful. Process-centered designers can (temporarily) ignore non-workflow related details to focus on process.


“[on Activity-Centered Design] understanding your users as people is far less important than understanding them as participants in activities “ Activity-Centered Design

That’s it, in a nutshell. Focus on processes surrounding users, then workflow roles, then users who fill the roles. At its core, that’s process-centered EHR design. Workflow management systems, business process management technology, and case management software make process-centered design easier. If healthcare needs process-centered EHR design and process-centered EHR design needs process-oriented EHR information systems then healthcare needs process-oriented EHR information systems.

That has been the message of this blog from its very beginning, three years ago: Welcome! (EHR + WfMS = EHR WfMS).

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  1. Posted May 16, 2012 at 5:39 pm | Permalink

    This is contrarily written indeed. User centered design is more important than workflow. If the user can’t understand the screen, then the workflow doesn’t work.

  2. chuckwebster
    Posted May 16, 2012 at 6:11 pm | Permalink

    Hi Mike!

    You’re right. It is contrarily written!

    Just trying to provoke some discussion.

    Ideally we need both: intuitable screens and usable workflows!

    By the way, really like your blog No World Borders at


  3. Jeff
    Posted August 27, 2012 at 11:39 am | Permalink

    The crux of the argument seems to hinge on this characterization of Human-Centered Design:

    “The methods of HCD seem centered around static understanding of each set of controls, each screen on an electronic display. But as a result, the sequential operations of activities are often ill-supported.”

    I would argue that designing each screen in a vacuum is a failure of the designer, but not a failure of HCD itself. If designers understood the context and environment in which these systems are used, the user experience would be complimentary to efficient processes/systems, and not working against them.

  4. chuckwebster
    Posted August 27, 2012 at 1:23 pm | Permalink

    Well said, Jeff!

    What I find most interesting about Norman’s argument is (A) he’s considered by some to be the father of user-centered/human-centered design and (B) he’s reacting against *something* in what user-centered/human-centered design has become.

    I have no problem with UCD applied to EHRs except this: it’d be more successful if the EHR workflow were more instrumented, more malleable, and more systematically improvable.

    By more instrumented, I mean usable event logs usefully mined to find usability issues.

    By more malleable, I mean ability for non-programmer users, familiar with their workflows, to change EHR workflow to their liking.

    By more systematically improvable, I mean combining the former and the later in such a way as to drive incremental usability improvement.

    Doing these three things will be easier with process-aware technology currently diffusing into health IT from workflow management, business process management, and adaptive case management.

    Ideally, I’d like to see the best of UCD philosophy and methods combined with an EHR technology that can meet it half way.

    Thesis, antithesis, synthesis!



  5. chuckwebster
    Posted October 9, 2012 at 8:25 pm | Permalink

    Clay Christensen, of The Innovator’s Dilemma/disruptive technology fame, recently, reportedly, said something consistent with DN (and my) point. Understanding workflow is more important than understanding users!

    “But Christensen said that many businesses and startups often make a mistake here, one that may, at first glance, appear counterintuitive. “Understanding the customer is the wrong thing to do — it’s confusing,” he said, before citing Peter Drucker’s assertion that customers rarely buy what companies think they are selling.

    Instead, what’s really important is understanding the job that customers are trying to accomplish, and only once an entrepreneur truly understands the need that a product or service fulfills for the buyer can they optimize their business or product.”

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