2006 EHR WfMS Tutorial Slides 23-29: EMR EHR Usability Principles and Workflow: Naturalness

(Take me to the beginning of these slides!)

From Chapter 7: Natural Language Processing, Business Process Management, and Adaptive Case Management in Healthcare in How Knowledge Workers Get Things Done: Real-World Adaptive Case Management:

“Naturalness” is one of the hardest to define usability qualities. It involves con-formance, or fit, of a tool to the human, whether it is a glove, favorite shoe, smartphone or EHR. Cognitive science approaches to naturalness range from af-fordances (handles on coffee cups) to similarity between problems (such as creat-ing accounting statements) and representations (spreadsheets). That discussion quickly becomes arcane. The best judge, of whether an EHR’s workflow feels natural, is how it feels to you. At each step of charting a patient, for example, the next thing you need to do should be obvious to you. Of the five workflow usability principles naturalness is perhaps the most subjective. It may also be the most important.”


  • “in conformity with nature”
  • “functioning in a normal way”
  • “expected and accepted”
  • “having all the qualifications necessary for success”
  • “suite by nature for a centain purpose or function”
  • “in accordance with human nature”
  • “ordinary and logical”
  • “as one would expect”
  • “freedom from constraint”


First, an electronic health record workflow management system more naturally fits the task structure a physician’s practice.


Riding a bicycle is an example of a natural fit between a user and a tool.


Bicycles are such a good example of natural fit between purpose and design that physicists conduct research into creating unnatural bicycles that are intentionally difficult to ride, that is, have an unnatural fit between user and tool.


A spreadsheet is another example of a natural. Donald Norman, father of user-centered design, talks about the Gulf of Interpretation and the Gulf of Execution. To anyone used to working with income statements and balance sheets, the required mental effort to map between the computer’s digital spreadsheet and the user’s mental spreadsheet is a short distance indeed. (My undergraduate degree as in Accountancy, so I know a bit of this history.) The spreadsheet was the original so-called killer app. Many small business people bought their first desktop PC solely to use a spreadsheet.

A natural “fit” between a user and an application is one that minimizes the twin gulfs of interpretation and execution.


EHR Naturalness

  • Does the interface “fit” the task?
  • Does screen content and sequence mirror task structure?
  • Does the EHR require users to do anything to the information before it is entered of after it is retrieved? (Post-it notes!) [CW: If so, this is a sure sign that gulf of interpretation and gulf of execution have exceeded working memory. This will be experience is high cognitive effort.]
  • Do users have to look up, annotate, or reorganize any information outside of the EHR? [CW: Again, this indicative of large gulfs of interpretation and execution]

Here’s an example of the EHR workarounds that create enormous gulfs of interpretation and execution. It’s from a recent Wall Street Journal article titled Physician, Steel Thyself for Electronic Records: Who’s got time to listen to patients when the government demands ‘meaningful’ data entry? (Summary here, if you don’t subscribe)

“When the clicks don’t get me what I want, I naughtily handwrite a prescription. I skip ordering certain tests I might want because it takes too much time—I’ll do it next visit”


This was an animation of a series of EHR screens interacting with some seriously cheesy/creepy hands that came in from off screen to touch buttons and data entry pick list items. This is just what that animation looked like, as a screen capture, with all the intermediate screens and hands stacked up on each other.


Natural Workflow

  • Degree of match between application behavior and task structure.
  • Multiple task structures stretch across multiple users in multiple roles.
  • Task analysis must span all users and roles.
  • Creating a process definition is task analysis
  • (and results in a machine executable representation of task structure)

(Take me to the beginning of these slides!)

Related links:

EHR/EMR Usability: Natural, Consistent, Relevant, Supportive, Flexible Workflow

TEPR 2004 EHR Workflow Management System Slides

Based on the slide deck used for three-hour tutorial at the 2004 TEPR conference in Fort Lauderdale.

TEPR 2006 EHR Workflow Management Systems Slides

Based on the slide deck used for three-hour tutorial at the 2006 TEPR Conference in Baltimore.


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One Comment

  1. chuckwebster
    Posted November 5, 2012 at 6:03 pm | Permalink

    Re the subject of a natural, ie good, fit between bicycle and rider I found this wonderfully detailed slide deck that really gets into the weeds on the topics!


    Slide 15: “Good bike fit is paramount for comfort, efficiency, and performance.”

    Reasoning, by analogy back to the definition of usability: performance is effectiveness; efficiency is, of course, efficiency; and comfort is user satisfaction (close enough).

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