So I was at TechfestNW earlier this fall and I had the opportunity to hear James Keller at WalmartLabs speak about the importance of having a minimum valuable (versus viable) product that is tied into the user experience. It is how the user’s emotional response to the application’s interface, which is so important to have, that gives a product meaning.
And this concept (although I admit I completely stumbled upon it) is at the very heart of what makes NOSH ChartingSystem so different. As I have stated on my blogs before and on my Indiegogo campaign site, I wanted to have an EHR that was both intuitive to use AS WELL AS having an interface that was calming and meaningful at the same time. So as an example from the medical world, having a pain scale is pretty good indicator of how user-friendly your application is.
An analogous concept is the OMG-to-WTF scale (see above).
Where does your EMR stand on the scale?
Continue reading “The OMG to WTF? EMR Pain Scale”
Filed Under: Tech
Tagged: Design, EHR, HIT, Michael Chen, Patients, Physicians
Nov 19, 2013
Remember the Ford Pinto and the AMC Pacer, aka the Pregnant Pinto?
Both serve as reminders of an in era in which the American auto industry lost its way and assumed drivers would buy whatever they put on the lot. Foreign competition, primarily from Japan, filled the void created by American apathy for quality and design, and the industry has never been the same.
Admittedly, the comparison of cars and EHRs is less than apt, but health IT also assumes healthcare will buy what we’re selling because the feds are paying them to. And, like the Pinto, what we’re selling inspires something less than awe. In short, we are failing our clinical users.
Why? Because we’re cramming for the exam, not trying to actually learn anything.
Myopic efforts to meet certification and compliance requirements have added functionality and effort tangential to the care of the patient. Clinicians feel like they are working for the system instead of it working for them. The best EHRs are focused on helping physicians take care of patients, with Meaningful Use and ICD-10 derivative of patient care and documentation.
I recently had dinner with a medical school colleague who gave me insight into what it’s like to practice in the new healthcare era. A urologist in a very busy Massachusetts private practice, he is privileged to use what most consider “the best EHR.”
Arriving from his office for a 7 PM dinner, he looked exhausted, explaining that he changed EHRs last year and it’s killing him. His day starts at 7 AM and he’s in surgery till noon. Often double or triple booked, he sees 24 patients in the afternoon, scribbling notes on paper throughout as he has no time for the EHR. After dinner he spends 1.5 to 2 hours going over patient charts, dictating and entering charges. What used to take 1 hour now requires much more with the need to enter Meaningful Use data and ICD coding into the EHR. He says he is “on a treadmill,” that it should be called “Meaningless Use,” and he can’t imagine what it will be like “when ICD-10 hits.”
My friend’s experience is representative, not anecdotal. A recent survey by the American College of Physicians and American EHR Partners provides insight into perceptions of Meaningful Use among clinicians.
According to the survey, between 2010 and 2012, general user satisfaction fell 12 percent and very dissatisfied users increased by 10 percent.
Continue reading “Darwinian Health IT: Only Well-Designed EHRs Will Survive”
Filed Under: Tech
Tagged: Design, Edmund Billings, EHR, HIT, ICD-10, Meaningful Use
Oct 23, 2013
Levels of Empathy for the User (i.e. the Patient) for Designers compared with Doctors.
Joyce Lee, MD is a pediatrician, diabetes specialist, and Associate Professor at the University of Michigan. She blogs about design and healthcare at joycelee.tumblr.com.
Filed Under: THCB
Tagged: Design, Joyce Lee, patient engagement, Physicians, Tech
Sep 15, 2013
The original Hipoocratic Oath states:
I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.
One modern version reads:
I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.
The idea here is that a doctor needs to recognize when another practitioner has a skill that they do not, and that they must refrain from “practice” when another person has demonstrable expertise in that area of practice.
It is now 2013. It is time for doctors to stop “writing their own EHR” from scratch. They need to bow out of this in favor of people who have developed expertise in the area.
I just found out about another doctor who has decided to write his own EHR, because he has not been able to find one that supports his new direct pay business model adequately. In the distant past I encountered a doctor who believed that his “Microsoft Word Templates” qualified as an EHR system. This is a letter to any doctor who feels like they are comfortable starting from-scratch software development for an EHR in 2013 or later.
You might believe yourself to be an EHR expert.
Are you sure about that? Are you sure that you are not just an EHR expert user?
This difference is not unlike your relationship with your favorite thoracic surgeon. Or for that matter, your relationship with the person who built your car. The fact that you are capable of expertly evaluating and using EHR products does not mean you are qualified to build one. Just like the fact that you are qualified to treat a patient who has recently had heart surgery or to discern when a patient might need heart surgery does not make you qualified to perform that heart surgery. Similarly, the fact that you can drive, or even repair your automobile, does not provide you with the expertise you need to build a car from scratch.
The ethical situation that you are putting yourself in by developing your own EHR is fairly tenuous. Performing heart surgery without being a heart surgeon, building and driving your own car without being an automotive engineer and a doctor coding their own EHR system from scratch all have the same fundamental problem: You might be smart enough to pull it off, but if you don’t you can really mess up another person’s life. Make no mistake, you can kill someone with a shoddy EHR just as easily as by performing medical procedures that you are not qualified for or by driving a car that is not road-safe.
Continue reading “Why Doctors Should Stay Out of the Business of Building EHRs”
Filed Under: Physicians, Tech, THCB
Tagged: Design, EHR, Fred Trotter, HIT, Patient Safety, Physicians, practice of medicine
Aug 26, 2013
Most people I work with in medicine have never heard of GitHub .
For the unfamiliar, GitHub is an online repository, which is an essential tool used by computer programmers to store their programming code. It has a number of virtues, including giving users the ability to track multiple versions of their code (sort of like remembering all the track changes you ever made to your word document). This is an essential tool for programmers but its value goes beyond its function as a track changes repository, as it is a site that facilitates open source collaboration, given its “social” features, similar to social networks like Facebook or Twitter, in which you follow the content of others or others follow you.
The most amazing thing about GitHub is that many users post their code (their work, their blood, sweat, and tears) publicly on their GitHub profile. Individuals will comment on others code, providing valuable input that the owner of the code can use to improve their work. In addition, can “fork” another person’s code repository, and work directly on the code in their own Github profile to make changes or improvements, sort of like a tag team collaboration. GitHub is the tool to help facilitate large-scale open source collaboration for the software/web programming world (such as that which lead to the Linux revolution).
By early 2012 there were apparently 1.2 million users hosting over 3.6 million repositories. Now that’s collaboration to scale!
So again, you may ask, why should physicians or medical researchers care about GitHub? Because it can have broader application beyond the software/web programming world, as shown by its use among non programmers, who are currently repurposing Github to advance collaborate in their own respective fields. They are posting book projects and transcripts of talks on the site, to encourage conversation and collaboration. One user even published his personal DNA information to encourage development of open-source DNA analysis. It has been suggested that Github could even be used by US citizens to “fork” the law so that they can propose their own amendments to their elected officials.
How might we use Github to democratize the world of medical research?
As researchers we do so many different activities that we perform in isolation, which forces us to “reinvent the wheel” constantly, from drafting of ethics board applications, to creation of research protocols, to the writing of snippets of statistical code or code for web programs.
Continue reading “GitHub: How an Open Source Programming Tool With a Funny Name Could Help Revolutionize Medical Research”
Filed Under: Tech
Tagged: Design, Github, Joyce Lee, medical research, open access
Jul 28, 2013
In Shirie Leng’s excellent post, “The Email I Want to Send To Our Tech Guys But Keep Deleting“, Dr. Leng lists a series of problem areas which plague software development in healthcare. Making things better requires taking a closer look at the specs we use. The new-age consumer-focused software companies can build products with outstanding usability because they start and end with the specs.
I have spent time at several academic medical institutions, and their software solutions are very much the same. At one, I was given this five-page table of portals and documentation systems with instructions on how to log in.
The punchline: I’m asked to have a different username and password for each of them.
I give much credit to the physicians who navigate these software applications, including the one that compiled the list I showed above. But physicians have allowed poor design of their technological solutions for too long, and have neglected to demand interoperability from software vendors.
The number of required training hours is a good indicator of usability. (And many of the items on the list come with long training hours.) While physicians have accepted these courses as part of their jobs for years, why should formal training be necessary to operate an EMR? Most of the tasks of ordering and documentation are no more complicated than paying your credit card bill or shopping online.
I’ll only scratch the surface of this usability problem by highlighting several notably poor implementations. I won’t even get into the inefficiencies in ordering and documentation.
My first example is an EMR system that is used to order medications and communicate data with nurses [below]. At a glance, there are no fewer than seven distinct menus on the screen at the same time. In my experience using this EMR, I’ve clicked ten percent of these buttons (and I would estimate that 90% of the work occurs in 5% of the buttons). The poor organization of information leads to lengthy searches for the right information, and often, the unawareness of critical information that is hiding under a nondescript label.
Lesson: Menus should have clear hierarchy.
My second example is a shift-scheduling application [below]. Here is an example of of how applications can invent interfaces rather than using the ones familiar to us. The primary menu is on the left-hand side. Upon clicking on one of these options, the secondary menu is displayed right below the header. The tertiary menu, however, goes back to the left-hand side. The issue here is a lack of consistency and predictability.
Continue reading “How Programmers Think: A Doctor’s Guide to Building a Better EMR”
Filed Under: Tech
Tagged: David Do, Design, documentation, EHR, HIT, Hospitals, Innovation, Physicians, Usability
Jul 26, 2013
I love interactive data visualization (#dataviz). It is one of the things that I definitely wanted to explore when I came out to the Bay Area on sabbatical, because I believe that it has great potential for helping both patients and clinicians with diabetes management. The sheer volume of numbers available for this disease is overwhelming; we need #dataviz tools that can help us achieve greater understanding and make actionable clinical decisions to improve health.
This is what we usually see in clinic: numbers written down on a piece of paper.
Yes there are computer systems that link to blood glucose meters, but there are a number of complexities with the downloading of blood sugar numbers in clinic (which deserves an entire blog post sometime in the future).
You can see there is some visual analysis and annotation that we do perform, albeit primitive. The circles represent high blood sugars (>150 mg/dl)and the triangles represent low blood sugars (<70 mg/dl). This is almost better than the cave painters don’t you think?
But even the minority of patients who download their BS to the computer, are viewing dashboards like this.
Pie charts, need I say more? I can extract some useful insights from these charts, which improve over the previous one I showed, but a few things strike me: (1) some of the scatter plots overlay weeks of data, which I don’t find helpful because you can’t tell how BS on a given day are responding and relate them to life events; (2) some visualizations show a lot of numbers in many of the sections, and it just becomes onerous to go through them and find trends; (3) many provide statistics (area under the curve, MAD%) which I think only a minority of families and children really understand; (4) although some of the software programs do provide interactivity and let you see the data at different time scales (day, week, month), if you change to a different view, you are stuck trying to remember in your head what you saw on a previous screen because you can’t see the multiple levels at once; (4) finally, I find that the user interface and design could use major improvement.
Continue reading “#Dataviz + #Design + #Diabetes: The Beginning”
Filed Under: Tech
Tagged: Data, Design, Diabetes, Joyce Lee, mHealth
Jun 14, 2013
What user personas do healthcare technology designers and entrepreneurs have in mind as they create their products? And how often is it the family caregiver of an elderly person?
This is the question I found myself mulling over as I wandered around the Health Refactored conference recently, surrounded by developers, designers, and entrepreneurs.
The issue particularly popped into my head when I decided to try Microsoft Healthvault after listening to Microsoft’s Sean Nolan give a very good keynote on the perils of pilots and the praises of platforms (such as HealthVault).
As some know, I’ve been in search of apps and services that can help older adults and their families keep track of lengthy and frequently-changing medication lists. For years now I’ve been urging family caregivers to maintain some kind of online list of medications, but so far I haven’t found a specific app or service to recommend.
Why? Because they all require way too much effort to enter long medication lists. Which means they are hardly usable for my patients’ families.
Could HealthVault do better? Having heard generally promising things about the service these past several months, I signed up and decided to pretend I was the daughter of one of my elderly patients, who had finally decided to take Dr. Kernisan’s advice and find some online way to keep track of Mom’s 15 medications.
Sigh. It’s nice and easy to sign up for HealthVault. However, it’s not so easy to add 15 medications into the system. When I click the “+” sign next to current medications, I am offered a pop-up box with several fields to complete.
Continue reading “Designing for Caregivers”
Filed Under: Tech, THCB
Tagged: caregivers, Design, Geriatrics, Health: Refactored, HIT, Leslie Kernisan, Long Term Care, Microsoft Healthvault, Tech
May 25, 2013
In November 2012, the digital team at HealthEd embarked on a challenge to redesign the face of personal health records. That effort has been rewarded with a first-place win in the category of Best Lab Summaries. And another HealthEd entry was cited as a finalist that “inspired the judges and challenged the status quo.”
About the Health Design Challenge
The Office of the National Coordinator of Health Information Technology and the Department of Veterans Affairs issued a challenge to designers throughout the United States: imagine how personal health records could be improved for clarity, readability, and visual appeal. Given HealthEd’s mission to create better outcomes in personal wellness, the team embraced the Health Design Challenge with typical enthusiasm.
The Health Design Challenge was more than an exercise in graphic design, however. Entrants were required to demonstrate expert knowledge of clinical systems and to render information of relevance for both millennials and senior citizens. The judges wanted more than pretty pictures—participants had to know their stuff. Continue reading “Redesigning the Personal Health Record”
Filed Under: Tech, Uncategorized
Tagged: Department of Veteran Affairs, Design, EHR, Health Design Challenge, HealthEd, Kel Smith, ONC, personal health records
Feb 9, 2013
“Hey doctor, what do you think about this product/solution/service?”
These days, I look at a lot of websites describing some kind of product or solution related to the healthcare of older adults. Sometimes it’s because I have a clinical problem I’m trying to solve. (Can any of these sleep gadgets provide data — sleep latency, nighttime awakenings, total sleep time — on my elderly patient’s sleep complaints?)
In other cases, it’s because a family caregiver asks me if they should purchase some gizmo or sensor system they heard about. (“Do you think this will help keep my mom safe at home?”)
And increasingly, it’s because an entrepreneur asks me to check out his or her product.
So far, it’s been a bit of a bear to try to check out products. Part of it is that there are often too many choices, and there’s not yet a lot of help sifting through them. (And research has shown that choices create anxiety, decision-fatigue, and dissatisfaction with one’s ultimate pick.)
But even when I’m just considering a single product and trying to decide what to think of it, I find myself a bit stumped by most websites. And let’s face it, if I visit a website and it doesn’t speak to my needs and concerns fairly quickly, I’m going to bail. (Only in exceptional cases will I call or email for more information.)
So I thought it might be interesting to try to articulate what would help me more thoughtfully consider a product or service that is related to the healthcare of older adults.
Continue reading “How Doctors Think About New Technologies”
Filed Under: THCB
Tagged: Data, Design, Entreprenuership, Geriatrics, Startups
Jan 30, 2013