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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I-am-not-worthyThere is an electronic medical record program (EMR) called DocuTAP that I use at one of my jobs. It’s not bad overall, and it’s the top-rated Urgent Care Center EMR. But, as with every EMR, it can be improved. In many ways.

I just ran across another new way in which it can be improved. This is a small issue, almost trivial. But as we discussed in Kludge, little issues, when they occur frequently, can have major impacts on usability, efficiency, and user satisfaction.

What’s the issue? In a particular circumstance, the computer doesn’t pay attention. It ignores me when. If this happened once or twice, I wouldn’t think too much about it. But since the computer keeps ignoring what I say on a regular basis, I start to think it’s deaf, incompetent, or maybe it’s just being mean. Read the rest of this entry »



On occasion, an academic paper is published, but one of the following Letters to the Editor or editorial is much more important, with a longer-lasting influence than the original article. An example is an editorial about sore throats/tonsillitis by Dr. Centor, of Centor Criteria fame. Well, now we have similar situation in the field of medical software usability.Kludge with duct tape

An article in the Annals of Emergency Medicine discusses a method to help prevent wrong-patient order entry: introducing a popup with name, age, and sex, chief complaint, bed location, length of stay, and recent medication orders, but also a mandatory 2.5 second pause. If you’re interested in informatics, I don’t recommend the article, as it discusses an inelegant, klunky, duct-tape-type workaround that should never be emulated.

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Ebola VirionLet’s suppose it is 1980. Suppose someone shows up in your ED with a fever, and a history of travel to an area with a new plague characterized by fever. The nurse has heard about this on the news, asks the patient about travel to the area, and gets a “yes.” The nurse not only writes this on the paper chart, but tells one of the ED doctors about it. The patient is correctly identified as a possible plague carrier, and admitted into an isolation room.

1950s Emergency Room

Mid-20th-Century Emergency Room

Let’s now suppose it is 2014. There is a shortage of primary care physicians. Primary care physicians no longer see emergencies, even minor emergencies, in their offices. EDs are much, much busier, and overcrowded. As a way to make things better (and, let’s be honest, to make money), vendors have developed electronic medical record systems (EMRs). Physicians, nurses and other ED staff give these hospital-wide EMRs low grades for usability, but the Federal government has been dangling big bags of money in front of hospital administrators as an incentive to buy an EMR. The government succeeded in persuading hospitals to go ahead full-bore with hospital-wide EMRs irrespective of their poor usability.

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