Norman Doors and Healthcare IT

May 7, 2018
Evidence suggests mixed results when it comes to overall EMR use and functions like clinical decision support providing concise, actionable information, and leveraging AI and predictive analytics. Is there a prescription for provider-centric HIT?

In the Harvard Business Review article, “How the EMR is Increasing Innovation and Creativity in Healthcare,” A. James Bender and Robert Mecklenburg provide a field report on how Virginia Mason is leveraging the electronic medical record (EMR) to drive improvements in clinical performance. They point out how digitizing clinical care could improve safety and ensure necessary and appropriate care.

Your Mileage May Vary

In contrast to the reported success at Virginia Mason, much of the available national evidence suggests mixed results when it comes to overall EMR use and functions like clinical decision support (CDS), providing concise, actionable information, and leveraging AI and predictive analytics. It’s also clear that end-user satisfaction remains low and contributes to burn-out in the clinical workforce.

Mostly what’s going on here is a lack of user-friendly applications that reflect the nuance and needs of individual users. The remedy: personalized, provider-centric health IT (PC-HIT) with intuitive user interfaces that present actionable information. This is not optional. PC-HIT is critical to building and maintaining a productive and sustainable workforce and an essential (if neglected) building block in achieving the IOM triple-aim, high-reliability and a culture of safety.

“Done to” or a “Reflection of” Clinical Staff?

It’s usually readily apparent which organizations have imposed HIT (“done to”) from the ones where HIT is a collaborative team sport (“done with”). Wise organizations invest significant resources in clinician engagement. They build effective and inclusive IT governance and robust and varied communication strategies. They engage actual front-line end-users and minimize relying on “stand-ins,” like managers or former clinicians. They understand that the further you move from the front line, the more likely you will end up with designs based on the organization’s officially prescribed workflows and “work as idealized,” rather than the reality of “work as done.”

End-users are clever and dedicated to efficiently caring for patients. If a workflow fails to conform to their reality, they will adopt workarounds. In the worst cases, frustrated or confused users simply refuse to follow the workflow. Unfortunately, workarounds and non-compliance can have adverse consequences that range from minor to catastrophic. In our experience, robust clinician engagement leads to better adoption, proficiency and achievement of clinical, operational and financial goals.

“Norman Doors” and Health IT

Far too many HIT applications reflect a disregard for basic principles of human factors engineering. The results are predictable. Systems are difficult to use, resulting in weak adoption, unnecessary variation, high error rates, general dissatisfaction and end-user fatigue.

What exactly do we mean by human factors and design? Have you ever pulled a door handle only to discover that the door must be pushed open? Most of us react by feeling foolish and blaming ourselves but, as Don Norman explains in his excellent book, The Design of Everyday Things, this is misguided. When it comes to Norman Doors, the real shame lies with the designer who failed to account for basic human factors. After all, handles signal they should be pulled, not pushed.

Labels like “push” are a sign of poor design. If you want humans to push, give them a push plate!

Sadly, there is an abundance of Norman Doors in HIT:

  • Rampant overuse of detailed prompts, reminders and hard-stops (CDS) that don’t take context or clinical urgency into account.
  • Countless clicks and pop-up windows that lead to confusion and end-user fatigue.
  • Unwieldy note templates that fail to consistently yield meaningful clinical documentation.
  • The need for scribes to act as a human “interface” between clinician and cumbersome EMR workflows.
  • Lack of robust interoperability between EMRs and other applications that forces end-users into inefficient, unsafe workflows and creates data silos.
  • Data-rich-information-poor (DRIP) designs with unwieldy text and tables due to a dearth of impactful visualization tools and user-friendly displays.

A Prescription for Provider-centric HIT

When we commit to provider-centric HIT, we are taking a vital step towards prioritizing the personal preferences and needs of the provider community. This is not at odds with the need for standards and to decrease unnecessary variations in care. It is expressly not a license for chaotic enablement of individual foibles. Quite the opposite. It is the response to the crucial need to reflect the reality of the way providers work. The tools cannot be cumbersome, nor obstruct the primary goal of enabling patient care.

Fortunately, there are clear steps we can take to deliver on the promises of high quality HIT, and in turn, foster a sense of community and commitment among clinicians, patients and HIT professionals. There is a prescription for personalized, provider-centric HIT:

  • Deploy strong, representative governance for all stages of HIT life-cycle from problem definition to system optimization.
  • Adopt robust, multimedia, consistent communication strategies.
  • Incorporate observational studies and meaningful, direct engagement of front-line end-users.
  • Avoid paving cow paths and missing larger opportunities for innovation by frequently asking “why?” Then ask “Why?” again. And again.
  • Demand and seek greater competition within HIT so market forces can drive more rapid innovation.
  • Embrace and leverage the iron triangle of people, process and technology. Many organizations fail to invest in their people (engagement) and process redesign (workflow) in the mistaken belief that simply deploying technology will achieve the desired outcome. They rarely achieve high performance.

Making HIT Fun

Providers and HIT professionals must approach each other with curiosity and empathy. They should start with the presumption that everyone is united in the quest to provide outstanding care to patients and are committed to doing their best. IT professionals must acknowledge end-users struggle with the current generation of HIT and that it often fails to facilitate or needlessly obstructs these inherently noble and shared goals. Likewise, end-users need to acknowledge the practical limits and constraints of present-day HIT. This shared understanding and empathy will promote better engagement, new insights, wise compromises and greater satisfaction and performance.

It might even make the hard work of healthcare and HIT more fun.

Special thanks to Dr. Erin Jospe for her contributions to this article. Erin has been an internist for 20 years and has held numerous appointments as a physician executive in health systems, government committees and digital healthcare companies. She is currently the Chief Medical Officer at Kyruus. 

Dr. Dave Levin has been a physician executive and entrepreneur for more than 30 years. He is a former Chief Medical Information Officer for the Cleveland Clinic and serves in a variety of leadership and advisory roles for healthcare IT companies, health systems and investors. You can follow him @DaveLevinMD or email [email protected].

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