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Clever Trumps Sincere in HCIT Usability

March 19, 2013
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There’s been a lot of progress at many levels in the last year on the usability front. They include regulatory (2014 edition of Meaningful Use certification), user Interface attention and innovations, emerging centrality of mobile and speech recognition, and whole new ways to break the fixed mental mindset around getting work done.


At HIMSS earlier this month, there were 26 highly instructive presentations on the topic of usability. Arguably the best was Dr. Jeff Belden’s outstanding presentation, “Medication List Makeover: Usable lists for the task at hand.” The take home points are here, and they complement my related discussion and take home points on workflow and analysis of Medication Reconciliation here.

The other standout wonderful presentation on usability during the past year was Dr. Ann Bisantz’s “Cognitive Engineering for Health IT,” presented at Johns Hopkins in June 2012. Click here to see the video.


One of the important distinctions that Dr. Bisantz calls out is the separate, but overlapping disciplines of: 


1.   Human Factors (broader term that encompasses humans as part of the system),

2.   Cognitive Engineering (work demands on the individual humans), and

3.   Usability (interface design, typically at task level).


I’ve written extensively on the cognitive dimensions in HCIT in my Blind Spots blog series in which I present predictable biases and errors that have been well studied and have distinct safety, quality and cost implications. You can read each installment by visiting this page and clicking your choices. 


It’s in this context that I’d like to introduce the concept of making an explicit distinction between the end user’s mindset, and one being more characterized by sincerity or cleverness. The importance of mindsets has been elaborated extensively in the highly recommended book, “Switch: How to Change Things When Change is Hard,” by Chip Heath and Dan Heath. The specific passages citing Dweck and research by Amy Edmondson are especially relevant.


The story is a particularly vivid one for me. During graduate school, the class was assigned an overnight homework project that involved calculating what the best decision was in a particular patient care situation. We were taught to build out a tree, where every branch had some probability associated with it. The exercise was to fully draw out the tree, and then perform the multiplications for each branch to reach a conclusion.


The sincere approach to solving this problem and completing the assignment involved spending hours to do the work associated with all of the required branches. The clever approach, however, recognized that the final branches of every limb were identical. With this recognition, it was possible to complete task in less than five minutes. Clever indeed!


Recognizing these competing mindsets when looking to improve the usability of health information technology is vital. At every provider organization I have visited, there are almost always several providers who have figured out a clever way to achieve usability. These users’ techniques represent “bright spots” that should be identified, promoted, and replicated.


For example, one physician recently told me that his ambulatory documentation template makes reference in the review to the system’s HPI (history of present illness). Using this approach, he’s able to dictate almost his entire note into the HPI, and this has been approved by his local documentation compliance department. As a result, he has far fewer requirements in terms of clicking, navigating and typing, and is able to do his documentation in a manner he considers to be extremely quick and easy.


In conclusion, we have a ways to go before usability in health information technology is where we want to be. It’s often still too hard to quickly find the information that matters, review it in a safe, reliable, efficient and effective fashion, and directly take actions dictated by that information. When the usability issues in a particular situation require too much sincerity and too much hard work to get the task done, we should always look for the bright spots, those users who have found a clever way to get the same work accomplished in a far more usable fashion. In the language of Dr. Belden, sometimes a makeover is required. What are your clever thoughts?


Joseph I. Bormel, MD, MPH

Healthcare IT Consultant

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