I was recently invited to sit in on a meeting of the American College of Emergency Physicians (ACEP) ED Health Information Technology Safety Task Force. We were talking about medical error related to technology. (In your mind, substitute “technology” > “the @#$@#$ computer”). We were discussing how to make it easy to report errors and near-misses, and who should get these error reports. I opined that it depends on the seriousness, and that there is a continuous spectrum from “kill-the-patient” errors/near-misses to “annoying, slowed me down so I made a mistake,” and that usability contributes to “computer” errors. I will now demonstrate that this is true.

Emergency physicians are frequently interrupted.

Computer systems with high cognitive friction take longer to use.

Therefore, if you take longer to complete tasks on the computer, you are more likely to be interrupted.

Interruptions cause errors. In multiple ways.

Therefore, poorly usable computer systems cause increased medical error.

Quod erat demonstrandum.



A point-and-click electronic medical record (EMR) can be very fast, at least for simple, uncomplicated cases. However, some point-and-click EMRs try to convert the information from clicked checkboxes into English. The results, just like the corrections applied by a word processor spellchecker, or the misrecognition when you’re using speech-to-text on your phone, can be amusing. My recent favorite text was when I was at a Chinese restaurant after work and my wife, who was on her way home from something, texted me to bring home some tungsten fried rice. (It was supposed to be young chow = combination fried rice.) But my all-time favorite is what I first heard of as Ode to a Spellchecker.

Candidate for a Pullet Surprise
by Mark Eckman and Jerrold H. Zar

I have a spelling checker,
It came with my PC.
It plane lee marks four my revue
Miss steaks aye can knot sea.

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Sometimes usability is just typography. Or perhaps common sense. Look at the following demographic section at the top of a LabCorp lab report. (Yes, I like to name names. It’s OK: truth is an absolute defense against claims of slander.)

Imagine you’re working in a very busy ED and the follow-up nurse hands you a lab report with this at the top. Quick: How old is this patient? Male or female?


My reaction: AAAARGH! Yes, the reason I picked this example is because it really bothers me. And, because it provides a really good bad example which is excellent for teaching purposes.

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The Federal government has warped the fabric of healthcare. By giving away money. They’ve done this both to doctors’ offices and hospitals, for “meaningful use” of healthcare information technology. You get the money only if you use software that the Feds certified to meet their criteria. This is supposed to get us to rapidly have interoperable, highly-functional and easy-to-use electronic health records. But… yes, there’s always a but.American Flag Waving

One of the Federal electronic health record criteria is that the software has been tested for usability. And there’s the rub.

On February 21, 2012, the US National Institute of Standards and Technology (NIST) published (NISTIR 7804) Technical Evaluation, Testing and Validation of the Usability of Electronic Health Records. This establishes a process for usability testing, the EHR Usability Protocol (EUP):  The EUP is a three-step process … (1) EHR Application Analysis, (2) EHR User Interface Expert Review, and (3) EHR User Interface Validation Testing.

Federally-certified vendors of electronic health records have to use a User Center Design process (UCD), for testing the usability of their software. They must test their software against a minimum of fifteen end-users according to the certification rules. Specifically, they must:

  1. Tell which user-centered design process they used, and if it is not a standard process such as the NIST EHR usability protocol above, provide a detailed explanation of how it works.
  2. Provide user-centered design test results for eight specific different EHR capabilities.
  3. Once the product is certified, make the usability testing reports public, with how many and what kind of users tested the software.

(During this whole blog post and any discussion of the issues raised by it, you must understand that the term “electronic health record” includes other functions of a Hospital Information System, such as computer-based practitioner order entry. Not my definition, but the Feds and in particular NIST seem to think that ordering medications is a function of a medical record system.)

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Bad Apple

I don’t own, nor have I ever owned, any Apple products. I tell people I’m not cool enough to own anything Apple. Indeed, as I was writing this post, I just also wrote a Windows batch file; very not-cool.Rotten Apple

For a long time, I felt marginalized. But with the latest versions of Android and Windows, I am finally starting to feel a bit more cool. And I like Windows 10—this update brings many subtle interface changes which, taken as a whole, make my computer much more usable.

In a previous post, I discussed skeuomorphism: the attempt to make a computer screen look like a physical object. Apple played with skeuomorphism, some say to excess. User-interaction gurus despise gratuitous skeuomorphism like master Stickley cabinetmakers despise wood-grain vinyl. But Apple finally got away from this, eliminated much decoration and made user interfaces more usable.

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//commented out L sidebar 7/26/11 //