Many apologies for the delay in approving your comment, which is so spot on! (I usually respond to emails that are automatically generated when new comments await moderation, something failed this time, maybe *I* need BPM!)

I agree that older EMRs that were not based on workflow engines, process definitions, and graphical editors will have to play catchup, if they can. That said, a few of these older EMRs do have this wonderful combo, either custom built or based on third-party business process management systems. I especially excited by the myriad of BPM functionalities this opens up. Moving to a process-aware (executable declarative process model) foundation makes so much possible that addresses the heart of current EMR dysfunctionality, from process mining-enhanced business intelligence to cross-organizational workflows to greater usability though user-centered workflow design. I am convinced that EMR or EHR BPM (whatever you call it, HPM for Healthcare Process Management or CPM–oops, that’s taken–for Clinical Process Management) is about to explode upon the Health IT scene.

Delighted by your comment. It’s another hopeful datapoint in a trend toward more process-aware, BPM-style EMR/EHR workflow systems.

I wrote the following all of three years ago!

From: 2009 AAP NCE EncounterPRO Pediatric EMR Trip Report: Demos, Kickbikes, and Workflow

http://chuckwebster.com/2009/10/ehr-workflow/2009-aap-nce-encounterpro-pediatric-emr-trip-report-demos-workflow

Understanding of EMR Workflow and Business Process Management in Healthcare is Gradually Increasing

Picture a graph that depicts progress toward higher and higher levels of market understanding of, and appreciation for, workflow management systems, EMR workflow systems, and business process management. By “workflow” and “workflow management” I don’t mean the meaningless ad copy that is thrown around and sprinkled on most EMR brochures and vendor websites. By “workflow management” I mean the same thing as what professionals and academics and workflow and business process management system vendors mean in the workflow and business process management system industry.

The X axis for that graph is now 10 years long. Data points are based on an unscientific series of impressions and vignettes: questions I received from an audience, a presentation I attended, a conversation in our exhibit booth. I began to see material on the web besides my own around 2004, plus have an occasional encouraging conversation. But it wasn’t until recently that I began to get the impression of a large uptick surrounding recent discussions of certification, usability, and meaningful use.

At the 2004 Fort Lauderdale TEPR show a physician watched a demo of EncounterPRO, asked a couple of questions about the customizability of the screen sequences, and exclaimed “This is a workflow management system, isn’t it?” 2004 was the first of three years that I gave a three hour TEPR tutorial about workflow management systems in healthcare, so I assumed that he had just sat through that session, but he hadn’t. Before becoming a physician he had simply worked in one of the many industries in which workflow management systems are more prevalent. He’d seen them before and so could recognize one when he saw one again.

Another example: at this year’s AAP one of my booth mates said “Shoot, you just missed him! This fellow was walked by, saw our sign, stopped dead in his tracks, and exclaimed ‘Workflow System! I’ve seen lots in other industries, but I’ve never seen a workflow system in health care!” He was an ER physician not shopping for an EMR, but I thought you should know.” Shoot! I missed him! Add a data point to my 1999 to 2009 TEPR-HIMSS-MedInfo-AAP WfMS/BPMS Progress Graph!

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!

Chuck

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

All nine actionable insights in Nine Usability Mistakes Your Team is Probably Making (And How to Fix Them) will improve current EMRs and EHRs usability.

I do have one caveat.

Your EHR usability insights deserve a more instrumented and malleable EHR substrate than current EHRs typically provide.

Application of your usability insights to the current generation of structured-document-based EMRs and EHRs will only incrementally improve usability. However, their application to emerging structured-workflow-based EMRs and EHRs could quickly and inexpensively result in dramatic usability improvements.

Most current EMRs rely on structured-documents, but not structured processes. These EMRs have relatively frozen workflows. To compensate designers crowd too much information and data/order entry options per screen and force users to perform extra work navigating from screen to screen.

EMRs and EHRs with executable process models (AKA EMR workflow systems, EHR business process management systems, process-aware health information systems) are less work to use by their users. They reduce the physical activity (clicks) and the cognitive work (scanning and interpreting screens, deciding which screen to proceed to next) through execution of a user-editable process model by a workflow engine.

A process model provides constraining context so all and only relevant information and data/order entry options appear on each screen. The process model also reduces the navigational search space confronting the user.

Off the top of my head, here’s an outline applying your nine usability insights to process-aware EMRs and EHRs.

Nine EHR Usability Problems and How to Fix Them with Workflow Technology

1. 1. Displaying too much information and too many data and order entry options per screen
   • Use process definitions to choose screens
   • Use process definitions to choose what to display
   • Use process definitions to choose how to display
   • Allow user to directly (via software editor) or indirectly (via human scribe) edit process definitions
2. 2. Focusing on features and functions instead of workflows and processes (so-called EHR “Featuritis”)
   • The whole (workflow/process) really is more than the sum of the parts (features/functions)
   • Follow the 20/80 rule: (the most important) 20% of features in usable form is better than (the most important) 80% of the features in unusable form
3. 3. Mimicking paper forms instead of replacing them with a “glass cockpit”
   • Earlier aviation cockpit displays simulated physical gauges and switches
   • Current aviation cockpit displays do not
   • Current EMRs and EHRs are still in the “early” phase when they simulate paper forms
4. 4. Tweaking hunt-and-peck screens instead of facilitating user-redesigned workflow
   • Moving stuff around on a screen and formatting it differently is only low-hanging fruit
   • Tackle the real problems that frustrate users, especially unnatural, inconsistent, irrelevant, unsupportive, and inflexible workflows
5. 5. Not gathering and understanding real-world usability event data
   • Process mining detailed operational data can be used to interpret and improve usability
   • See Process Mining for Usability Tests
6. 6. Not respecting Fitts’s and Hicks Laws dictating bigger and fewer targets per EHR screen. (smartphones and tablets currently do this better than most desktop EMRs and EHRs)
   • Fitts’s Law: Larger, closer targets (buttons, hotspots, etc.) are easier to hit quickly and accurately
   • Hicks Law: Users more quickly and accurately choose from among fewer competing alternatives than more numerous competing alternatives
   • Therefore display fewer larger targets per screen (again, made possible through context constraints supplied by during workflow enactment by executable/executing process model)
7. 7. Not leveraging user-editable process definitions editors to improve screen sequence
   • User testing is all well and good
   • But use it in conjunction with user-editable screens and screen flows
   • The result will be a tighter, more productive edit/execute EMR user interface and user experience improvement loop
8. 8. Assuming usability ratings equal overall usefulness
   • Just because you can do something
   • Doesn’t mean you want to do something
   • Doesn’t mean you should do something
   • Use who-what-why-when-where-how context to make what you want to do and should do easy to do
9. 9. Waiting for meaningful use dust to settle before tackling:
   • EMR and EHR workflow with workflow engines (this whole blog)
   • EMR and EHR Usability with user event data (see above)
   • EMR and EHR Safety with process model checking (not discussed above, but see 1, 2, and 3)
   • EHR and EMR Productivity with BPM (business process management)

Your nine EHR usability mistakes potentially apply to both structured-document-based and structured-process-based EHRs, however their effects are different. Structured-document-based EHRs and EMRs have relatively frozen workflows. They have no means to use workflow execution context (”enactment” in BPM parlance) to intelligently decide 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.

All in all, your Nine Usability Mistakes Your Team is Probably Making (And How to Fix Them) is a great bundle of insights that will incrementally improve existing EHRs.

Incremental improvement of EMR and EHR usability is better than nothing in the short run. It won’t be enough in the long run.

EMRs and EHRs will need to be more “intuitive” (in the correct sense of the word) than will be possible without process models to usefully push screens to user like a good OR nurse hands instruments to a surgeon.

Thank you for your kind comment and an opportunity to read your white paper.

Cheers

–Chuck

Obviously the industry is taking note of usability in EHR systems as NIST has just recently put forward their usability evaluation guide (which I understand may be the basis for upcoming meaningful use stage 2 criteria)

For further reading on EHR usability and the root causes at this time, I invite you to check out my paper 9 Usability Mistakes Your EHR Team is Probably Making (And How To Fix Them) http://tinyurl.com/7n7rksg

You’re right, I do love big buttons. I write about big buttons a lot. You could say I have a thing for big buttons. I’m not alone among usability professionals. Fitts Law is well known in aviation human factors. Larger “targets” are more easily “acquired” quickly and accurately. This reduces cognitive effort and error.

However, simply having big buttons is insufficient. Needed is ability for users to program sequences of screens, and the data and order entry options on those screens, to customize EMR / EHR behavior to their local idiosyncratic workflow needs and preferences. And for the EMR / EHR to automatically chose and then execute these sequences intelligently given the evolving clinical context within which this execution occurs.

The only practical means to do both (big buttons *and* automated screens) is to use workflow engines executing process definitions. These are widely prevalent in other industries and just beginning to appear in healthcare. Obviously, these engines must give way to users, letting them jump out of workflows, jump back into workflows, reassign workflows, change workflows on the run, and so forth. These capabilities (under the guise of adaptive case management) are rapidly being added to workflow management systems in the business process management industry.

Given recent spikes in interest in User-Centered Design of EMRs / EHRs I am rereading Donald Norman and Stephen Draper’s 1986 edited collection User-Centered System Design: New Perspectives on Human-Computer Interaction (526 pages!).

On the very first page they write:

People are so adaptable that they are capable of shouldering the entire burden of accommodation to an artifact, but skillful designers make large parts of this burden vanish by adapting the artifact to the user. To understand successful design requires an understanding of the technology, the person, and their mutual interaction, and that is what this book is about….Human-Computer Interaction needs….many disciplines: computer science, psychology, artificial intelligence, linguistics, anthropology, and sociology-the cognitive sciences.

This passage, written more than a quarter of a century ago, applies in spades to most of today’s EMRs / EHRs. So much so that just a few word and phrase substitutions results in the following passage:

Physicians are so adaptable that they are capable of shouldering the entire burden of accommodation to an EMR / EHR, but skillful EMR / EHR designers should make large parts of this burden vanish by adapting the EMR / EHR to the physician (and other) user(s). To understand successful EMR / EHR design requires an understanding of EMR / EHR, physicians and their clinical team, and their mutual interaction…. Physician-EMR/EHR Interaction needs….many disciplines: computer science, psychology, artificial intelligence, linguistics, anthropology, and sociology-the cognitive sciences.

Starting with a product design course when I was an undergraduate, human factors and workflow courses as a graduate student, and finally coursework in all the cognitive sciences (except anthro, sorry to say, though I read it extensively), I continue to be fascinated by computational models of mind and community, and their relevance to building usable EMRs / EHRs. So I am delighted that you chose to post here and would love to hear more about how the HealthFusion EMR / EHR Meditouch addresses these impediments to widespread EMR / EHR adoption.

I’m thinking about writing a blog post with a title something like “User-Centered EMR / EHR Design is Good Product Design, Plus Lots of Cognitive Science”. How have you addressed EMR / EHR usability? How malleable (by users, not programmers) is your workflow? Can users edit workflow. Care to share a screenshot or two? Or, better yet, a video explaining how you avoid EMR / EHR “frozen workflow”? I’d feature any relevant screen shots or videos.

You certainly appear to be on the right track!

Thank you and

Cheers

–Chuck