Siemens Healthcare on solving EHR usability problems: you can just call up your pal at the next hospital

In my Aug. 2009 post "Why Siemens Healthcare Fails", I wrote:

I note that I used to admire German engineering rigor, but after seeing ill conceived, misguided position ads like the following from Siemens Healthcare, I am having sincere doubts about that country's current prowess in that domain.

My admiration fell another notch. I now see this, in a Feb. 1, 2012 article from HealthData Management entitled "User Unfriendly" on the flaws in commercial health IT that present a poor user interface/user experience (at the expense, ultimately, of you, the patient). The article's browser title bar somewhat subliminally reads "Physicians gripe that EHR's are not easy to use but improvements are coming":

... There's also no mechanism for publicizing problems with EHR interfaces, unlike the FDA's process for issues with medical devices. [User interface expert Prof. Ben] Shneiderman describes a case where a physician found a bug in an EHR that created a danger to patients. "He contacted the supplier because he thought it was something other users should know about, and the response was, 'Oh, we know-we're working on it,'" Shneiderman says. "The physician said, What? You know about it and you haven't notified everyone?' Contrast that with the Federal Aviation Administration, where problems with airplanes are publicized within hours."

The IOM report calls for substantial loosening of those contractual restrictions. "The committee views prohibition of the free exchange of information to be the most critical barrier to patient safety and transparency," the report says. "The committee urges the [HHS] Secretary to take vigorous steps to restrict contractual language that impedes public sharing of patient safety-related details. Contracts should be developed to allow explicitly for sharing of health I.T. issues related to patient safety." The report also says there should be a central place to report and publicize known issues with EHR software.

Siemens apparently has a different idea on taking responsibility for the user interfaces of their products:

Siemens Healthcare Chief Medical Officer Don Rucker, M.D., says the secrecy issue is overblown. "There are trailer loads of information out there on each of these big systems, and there are so many end users that you can just call up your pal at the next hospital."

There are trailer loads of information out there, and it's up to the end user physician to find the information and sort through it?

... Sounds perfectly reasonable to me. /not/

There are so many end users that you can just call up your pal at the next hospital [for guidance on user interface complexities and errors]?

Also sounds perfectly reasonable. /not/

... Except, I think most EMR vendors and user-organizations sort-of disable Remote Assistance, Remote Desktop and similar programs. Even "print screen" is usually either disabled or forbidden from sharing with that "pal at the other hospital." Might have something to do with security and IP protection.

Ever try to guide someone through a complex computer interface over the phone, blind, with no real-time mutually viewed visuals? It's not easy, but ... physicians and nurses have PLENTY of time for such fritter, what with the little other work they have to do.

I also think saying busy physician, nurse and other clinical customers should "depend on their pals at the next hospital" for information on health IT difficulties is a rather condescending and patronizing statement to make (to be charitable), a backyard-mechanic attitude, but that's just me.

Why does Siemens fail?

This type of statement is a very good clue.

-- SS

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HIMSS and Healthcare IT: We Don't Need A "Usability Maturity Model." We Need - USABILITY - and Less of Cold-Blooded Calculus

Health IT industry consortium HIMSS has followed up its Master of the Obvious, 50-years-too-late paper "Defining and Testing EMR Usability: Principles and Proposed Methods of EMR Usability Evaluation and Rating" (June 2009) that I wrote about in a Dec. 2010 post "Unintended errors with EHR-based result management: a case series, and a special pleading for health IT" with a new report:

Promoting Usability in Health Organizations: Usability Maturity Model (PDF, Feb. 2011)

I knew I was in for a heaping helping of gobbledygook after reading the title itself:

“Promoting Usability in Health Organizations: Initial Steps and Progress Toward a Healthcare Usability Maturity Model”

A “Healthcare Usability Maturity Model” is a clue that what follows will take simplicity, and expend considerable ink to tangle it into a mess of process mysticism, buzzwords, paradigms, very pretty charts, and other Master-of-the-Obvious-made-to-look-sophisticated, destined-for-the-dusty-shelf consultant report.

That is largely what follows. See for yourself.

This passage in the Executive Summary is pathognomonic of the amoral, money-over-blood, patients-as-guinea-pigs mentality that inhabits the commercial health IT sector. I find it particularly revealing and revolting:

... Leaders may be reluctant to incorporate usability principles and practices [in a safety-critical technology increasingly mediating all aspects of medical care delivery - ed.] because of perceptions that these methods may slow development and product fielding. However, data exist on usability return on investment (ROI), outlining the value of adopting usability in health organizations.

Excuse me? It takes proof of "ROI" to convince these companies to produce usable (which subsumes the concept of "safe") health IT?

This is as cold-blooded a calculus as it gets. This is Ford Pinto material:

... Critics alleged that the vehicle's lack of reinforcing structure between the rear panel and the tank meant the tank would be pushed forward and punctured by the protruding bolts of the differential^[15] [by a rear end collision of only 20 mph/32 km/h, causing a fire - ed.]— making the car less safe than its contemporaries.

According to a 1977 Mother Jones article, Ford allegedly was aware of the design flaw, refused to pay for a redesign, and decided it would be cheaper to pay off possible lawsuits for resulting deaths. The magazine obtained a cost-benefit analysis that it said Ford had used to compare the cost of an $11 repair against the monetary value of a human life—what became known as the Ford Pinto Memo.^[13][16][17]

An example of a Pinto rear-end accident that led to a lawsuit was the 1972 accident that killed Lilly Gray and severely burned 13-year old Richard Grimshaw. The accident resulted in the court case Grimshaw v. Ford Motor Co.,^[18] in which the California Court of Appeal for the Fourth Appellate District upheld compensatory damages of $2.5 million and punitive damages of $3.5 million against Ford, partially because Ford had been aware of the design defects before production but had decided against changing the design.

[In more recent years, others said the Ford Pinto scandal was not clear-cut, but health IT unusability increasing odds for medical errors is clear-cut - ed.]

Why are these companies and their leadership getting to play God - in a field such as Medicine?

Usability? Those Luddite doctors and crummy patients will get usability over my - er, their - dead bodies, if I don't profit handsomely from it.

Finally, I have several meta-observations about this new report:

• We don't need a "usability maturity model." We need USABILITY. We need the common and longstanding knowledge of software usability in other mission critical sectors to be applied on the development whiteboard and usability testing labs (if any!) at HIT vendors.
  

• Why is it that health IT usability has to be written about, basically as if from the grade school level, in 2011 - some sixty years into the “computer revolution?” Do we still write treatises on why it’s wise to use sterile technique and good lighting in operating rooms? What is the major malfunction in this industry?
  

• Why is this treatise not entitled “Promoting Usability in Health IT Vendor Development Shops: A Vendor Responsibility Model”?

• The frequent use of the terminology "user experience" as applied to healthcare IT in this report struck my eye. It has been adopted in this report, but was uncommon regarding health IT until recently, as in my posts about the health IT mission hostile user experience.
  

The terminology is conspicuously absent in the aforementioned earlier 2009 HIMSS report. It would not take Sherlock Holmes to theorize that I might be an unattributed contributor to the new 2011 HIMSS report. If anyone knows differently, I'd be interested to hear about it.

-- SS

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The National Program for Healthcare IT in the U.S., and the Elephant in the Living Room

The National Institute of Standards and Technology (NIST) has begun to address deficient clinical IT usability. A PDF with presentations on the topic from the recent NIST conference on HIT usability is here (warning: very large, 26 MB).

There is a critical "meta-issue" that's being ignored regarding usability, though, yet it is the elephant in the living room.

First, I will detail the elephant, then ask the simple, logical question that arises (the "inconvenient" question that nobody seems to be able to give a straight, non-marketing-spin answer to).

Here are the details of the elephant.

First, poor usability ---> increased risk to patients.

This is a first principle; it is not open to debate.

Now:

If NIST is just now getting involved in "improving HIT usability" (the improvement of which should have occurred at least two decades ago);

While HIMSS's former Chairman of the Board admits the technology remains experimental:

... We’re still learning, in healthcare, about that user interface. We’re still learning about how to put the applications together in a clinical workflow that’s going to be valuable to the patients and to the people who are providing care. Let’s be patient. Let’s give them a chance to figure out the right way to do this. Let’s give the application providers an opportunity to make this better;

While HIMSS itself admits in this 2009 PDF that

"Electronic medical record (EMR)!adoption rates have been slower than expected in the United States, especially in comparison to other industry sectors and other developed countries. A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available";

While the National Research Council (the highest scientific authority in the U.S.) last year reported that :

"Current Approaches to U.S. Health Care Information Technology are Insufficient" and that the technology "does not support clinicians' cognitive needs." The study was chaired by Medical Informatics pioneers Octo Barnett (Harvard/MGH) and William Stead (Vanderbilt);

While it's not just the user experience that's the problem, either...

Insurers are starting to recognize this, e.g., "NORCAL Mutual Insurance Company: "Electronic Health Records: Recognizing and Managing the Risks" ;

While hospitals and vendors cannot yet manage the technology reliably - how many medical mistakes have/will occur as a result of screw ups like this one, now confirmed to have occurred at a religious-denomination hospital chain headquartered in the Great Lakes region of the U.S.?

This patient won't get a second chance, either.

The above issues are the elephant in the living room. Or, shall I say, in the Boardrooms and meeting rooms where health IT is planned and discussed?

Health IT is great stuff, guys; it might actually work well one day!
Let's roll it out nationally and penalize those Luddite doctors
who refuse to "use it meaningfully" because it's not very usable.
Oh, just ignore that strange creature over there in the corner ...

Considering the size and weight of the elephant, here is my question:

Why are we rolling out this technology nationally under penalty of Medicare garnishment?

I cannot get a straight, unspun answer to that question.

Perhaps we need Bill O'Reilly to ask these questions of health IT officials on his FOX News program, The O'Reilly Factor, where spin is attacked relentlessly (the "No Spin Zone.")

-- SS

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