January 6, 2014, 2:00 pm / Jacob Reider, MD / Acting National Coordinator for Health Information Technology


The New Year is a time of reflection and anticipation. We reflect on what went well in the past (and perhaps what didn’t go so well); we anticipate future challenges and accomplishments.

As I reflect on the past, I can see that we’ve accomplished incredible things together.  The majority of care provided in United States hospitals and medical offices is conducted with the assistance of information technology. Our care is safer, more efficient, and provides research and measurement opportunities that were simply impossible with paper systems.

But as a physician who has used an EHR in my clinical life since 2001, I worry that some of the usability challenges that we early adopters tolerated “for now” (a decade ago) remain unresolved.

This is a problem.

Early adopters of technology are well known to tolerate imperfections. Traditional market forces generally keep products that are difficult to use from succeeding, and as any user of an Apple Newton remembers, the promise of an innovative solution isn’t always realized and will/should fail in the marketplace. Yet some have argued that the meaningful use incentive program altered market forces in a way that prevents well-intentioned products from failing as did Apple’s first “personal digital assistant.” Health IT is not the same as consumer electronics:

a)    The user isn’t always the buyer.  This causes usability to be a less significant component of buying decisions.

b)    Multi-year contracts and technical “lock-in” cause portability to be a true challenge.  One can’t just walk away from an EHR that’s not performing as expected.  Buying an EHR is more like buying an airplane than a clock radio.

c)     Legacy software in a high-risk environment will evolve slowly – for good reason.  One can’t change workflow or user experience too quickly, as changes in the user interface can increase error rates even if the new design is better for new users.  Errors can harm or kill people.  Developers need to evolve user experience slowly and carefully.  Usability won’t improve overnight.

d)    Health IT systems are complex and require local configuration. Inadequate local resources can cause well-designed products to offer terrible user experiences. To the end-user, they have no way of knowing who is responsible – the IT department or the software developer? Was it Boeing or United Airlines who made these seats so uncomfortable?

Do “I know it when I see it?“ or is there something more complex about enhancing/defining/recognizing usability in Health IT? How does the usability of HIT products have an impact of the quality and efficiency of care delivery? How can we help make HIT products more usable? What is usability?

The (ISO) definition of usability, referenced in the 2009 HIMSS usability primer is a good start:

“Usability is the effectiveness, efficiency and satisfaction with which specific users can achieve a specific set of tasks in a particular environment.  In essence, a system with good usability is easy to use and effective. It is intuitive, forgiving of mistakes and allows one to perform necessary tasks quickly, efficiently and with a minimum of mental effort. Tasks which can be performed by the software (such as data retrieval, organization, summary, cross‐checking, calculating, etc.) are done in the background, improving accuracy and freeing up the user’s cognitive resources for other tasks.”

About a decade ago, I was a young(er) family doc, helping physicians in my community learn about how to select and implement an EHR. This was a new domain for them, but they were engaged and enthusiastic. Asked to present the bullet list of criteria that they would use to select the best EHR, I often responded with the list that one would expect:

  • Write Notes
  • Write Prescriptions
  • Write Orders
  • Write Messages
  • Manage Lab results

But I knew this list wasn’t complete. The missing (and perhaps most important) bullet was usability. Here’s a version of some guidance to my local colleagues circa 2005 that includes the term “usability.” “Are you kidding?  Usability?” They asked me after the presentation. “Did you invent a new word?”

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