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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Information Design is the art and science (or perhaps engineering) of presenting information so it can be easily interpreted without error. Sometimes it seems that the presentation of data in electronic medical record systems is the art and science of presenting information so that it is difficult to interpret and highly likely to cause error. There may be what seem on first blush to be good reasons for presenting data this way – responding to legal concerns, regulatory abreactions to specific medical errors that occurred, or that might occur – but the end result can be ugly and dangerous.

Let me give a specific real-world example from a few weeks ago, from an EMR that shall remain nameless to protect the guilty. This is the way the EMR reports a fingerstick glucose:

     GLUCOSE [82947]
        GLUCOSE [82947]: 331 mg/di Abnormal High (GLUCOSE NON-FASTING
        Ref Range:80 to 180 mg/di Critical Low:70 Critical High:400)
        Fingerstick right 3rd digit. ac,rn
        non fasting

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Mouse CursorsUser experience (“UX” to the cognoscenti) is a burgeoning field. Used to be we called this computer usability, user interface design or user interaction design. It was focused mostly on software such as word processors, spreadsheets, industrial control software, airplane cockpits, and medical applications. But, given how much money can be made on the web, UX focus is now quite tightly on web usability, particularly e-commerce websites.

Early efforts at assessing usability were crude. For the most part, they are still crude. Early on, usabilitists (I just made that up) would count the clicks needed to perform a task. Cutting down the number of clicks was a simple way to make at least this particular task faster.

But these days, the Web UX community sees “counting clicks” as unbearably primitive and déclassée. As UX grew out of usability and user interaction design, and focused tightly on web-page design, dogma evolved, including “All pages should be accessible in 3 clicks.” But this dogma was later debunked: “Three clicks is a myth.” When people are browsing the web, more than 3 clicks are fine, as long as you continuously have “the scent of information” – that is, your clicks each result in more, and perhaps more specifically useful, information.

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