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Co-Creation is the Two-Way Street to Usability

June 15, 2016
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I was driving to the Office of the National Coordinator for HIT last week using my GPS map app to provide visibility on timing and traffic. As I got close, I saw new options appear with the label “Similar ETA.” As it turned out, I had a piece of information the GPS was missing. I knew that I could park for $2/hour on a nearby street. Garage parking, on the other hand, would cost $20. The GPS software and I were working to co-create my specific route. By focusing on being smartly flexible, the experience was highly usable.

As the medical director and program officer over usability at ONC in 2013 and 2014, I worked with dozens of experts contributing to the SHARP-C usability project. An important lesson learned from this project is that the essence of usability is improving visualization, analytics and workflow integration by co-creating solutions.  This usually involves a bit of clinical decision support, putting those reasonable "new options" on the screen for the user.

We are now in the era of value-based healthcare where HCAHPS scores play a huge role in reimbursement, and consumerism is a factor that cannot be ignored. Therefore, it’s time we rethink our path to usability. Are there opportunities to co-create it by giving providers and patients options to better identify evidence-based quality improvement opportunities? I think, yes! 

Private sector conveners need to step up and co-create specific usability solutions with standardized visualizations, analytics and workflows that enable us to achieve our national goals. Too many of the current approaches beleaguer providers and associations.  Implementors often discover and lament infeasible analytics and workflows.  The problem is more than insufficient quality assurance.  Without co-creation, our approach to decision support, measurement and inspection is too brittle. The necessary data, collection, workflows and specific action points don't scale when they lack the leadership of organizations like the AMA and AHA, clinical practices, and patient advocates. But they could and should. 

We know from experience that if we do not reframe usability as a two-way street by co-creating a path toward better quality, the term “usability” is an oxymoron. On our current path, we lack the ability to estimate a time of arrival, or even the likelihood of arrival.

What do you think?



Nice post.  Add the concept of a learning machine that becomes more familiar over time with the specific approach the clinician takes in diagnosing and treating the patient's particular problems and you have a much more organic process.  Couple that with the machine learning the preferences of the patient and you can start to improve satisfaction at the same time.

Thanks Joe.

You bring up a terrific point.  In contrast to building static documentation and ordering templates, we are starting to refinements in usability based on experience using live systems.

For readers interested in seeing this working in the real world, there was a great HIMSS educational session worth downloading.  Marc Probst (Intermountain) and Jeff Townsend (Cerner) presented "What IT Takes for Success" (HIMSS16_session 139.pdf), available for free here:

If you jump to slide 33, you'll see the analytics they did after go-live, related to making ordering far more usable.

You make some good points Joe, but if I may differ on a few of your suppositions...

First, while it is true that we are entering into an era of value-based payment, "value-based" is still IMO an emerging concept, and with way too much "fuzziness" in measurement and an ability to "game"  measurement with careful selection of measures.  Further, while I care very deeply about patient engagemenrt and experience of care, I do not believe it carries the same weight in payment as you do Joe.

Secondly, while what you say about usability is not wrong, you are assuming that all clinicians wish to accomplish the same endpoints as you or me.  I would suggest that many physicians would view usability as the number of clicks it takes to write a note that justifies their billing code.  Or, reconfiguring a system that surgical scheduling is better automated... Or eliminating rework and the necessity of form completion of prior auth.  As long as our payment model still values procedures over visits, and visits over information management and quality outcomes - usability to better achieve health information management and quality outcomes will likely be viewed as hypercomplexity.

Finally, while I understand that usability includes the concept of usefulness - I believe that until health care operations and administrative burdens are allowed to be made easier by health IT - we are short-changing our overburdened docs and staff.

Peter, Thanks for your comment.  I have no argument with any of your points.  It strikes me that your perspective is driven by the priorities of many practicing clinicians.  That is a good thing.

As we have recently discussed, I have been working on the quality measurement.  Getting that right and improving it is central to MACRA.

As Dr Zahid Butt described in his grand rounds, "Electronic Quality Measures and Clinical Decision Support - The twain shall meet soon !!”, and available in video here:

the lack of standardization of needed displayed information and workflow integration has been a challenge to measurement and improvement. 

It is a challenge that many other highly informed leaders think could be best addressed by the medical societies that aspire to contribute to improving the National Quality Strategy.

Dr Butt's presentation calls out that there are issues in care (e.g. Stroke Management, see NQF 437, Stroke 4 in his presentation) where there are logic flaws and infeasible data elements in the quality measures.  These flaws in endorsed measures have been acknowledged by CMS and standards development organizations.  It is fascinating to me that it is exactly these same issues that contribute to making EHRs more usable and safer.  It may be more of a leadership opportunity, than a fundamental flaw in technology or bad behaviors or intent on the Health Information Technology industry.  I include all of us, consultants, providers, vendors, payers, patients and plan members potential co-creators of a path forward.



An excellent post! You make several very valid and realistic points. I'm especially impressed that you haven't underestimated the importance of patient engagement. Physicians and hosptals that do will ultimaately lose their financial viability and ability to compete.

If you have time, I would appreciate your expanding upon the fourth paragraph. Could you provide some specifics about what the private sector needs to do in terms of co-creation? Perhaps there's a link available to a source of such information.

Keep up the great work, and many thanks.

Doc Ben

Thanks for your comment.

Dr Zahid Butt described variations in workflow as the norm, and is a major challenge to the world of implementing quality measures.  I cited his outstanding 2016 Grand Rounds, "Electronic Quality Measures and Clinical Decision Support - The twain shall meet soon !!”,  (video: in another comment.

This hyper-variation in workflow happens for understandable reasons, including the prioritization and timing of quality improvement work within each health system facility, and variations in their technology platform capabilities and needs.

The AHA and AMA, who I mentioned in the paragraph you referred to, have published Guiding Principles on Integrated Leadership, and have independently promoted HIT usability and quality measurement efforts (such as AHA's support for the "CMS eCQM pilots and demonstrations, to inform future rulemaking.") 

It seems likely that these and other professional associations could provide even more direction on workflow improvements necessary to drive usability and quality improvement.  This is hard to do.  It is requires investments by providers that are often not rewarded by the marketplace.  Associations seem to be uniquely positioned to provide that leadership.