EHR/EMR Workflow System Usability–Roots in Aviation Human Factors

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You may have noticed aviation-inspired terms, illustrations, and ideas on the High-Usability EncounterPRO EMR Workflow System website:

  • A pilot helped to design EncounterPRO’s user interface (UI). (Link)
  • EMR UI design is mimicking evolution from traditional cockpits to today’s glass cockpits. (Link)
  • The phrase EMR “rollout” derives historically from “rolling out” a new aircraft from its hanger for its first public viewing.
  • EncounterPRO’s Office View is like a radar view from an aircraft control tower, from where staff can see where everyone is and how long they’ve been waiting. (Link)
  • The illustration at the top of each fat footer sitemap is an aviation concourse. (Link)
  • Aviation human factors is an important subdiscipline within Industrial Engineering (which has many other useful applications within pediatric and primary care “production systems”).  (Link)
  • Then, of course, there is that cool helmet with an EncounterPRO screen projected on its wrap-around visor. (Link)


What if I told you that EHR/EMR workflow systems:

  • Reduce workload and difficulty of carrying out the phases of a patient encounter.
  • Relieve physicians of having to perform repetitive sequences that are unrewarding and for which human beings in their inconsistency can be at their best or their worst.
  • Endow physicians with the gratifying part of their jobs: decision making.

It would be true, but I would be paraphrasing page 176 of the Handbook of Aviation Human Factors in which it says that designers of cockpit automation hope to:

  • Reduce workload and difficulty of carrying out the phases of the flight.
  • Relieve pilots of having to perform repetitive sequences that are unrewarding and for which human beings in their inconsistency can be at their best or their worst.
  • Endow pilots with the gratifying part of their jobs: decision making.

I’ve seen many EMRs over the years, some designed by physicians, some designed by programmers, and many  designed by both. However, a physician, a programmer, *and* a pilot designed EncounterPRO—and it shows.

Aviation human factors techniques and ideas about individual and team performance have been used to improve patient safety (for example), but less so for sheer high-performance effective and efficient EMR data and order entry.  Since World War II, the aviation industry has spent millions (perhaps billions) of dollars on aviation human factors research on the design of high-usability, high-performance robust avionics and cockpit management systems. Many aspects of traditional EMR design contradict  this accumulated knowledge and experience.


As a result, an EMR Workflow System looks and works differently from any other EMR of which I am aware. While I wouldn’t want to fly a plane using EncounterPRO as cockpit management software, of the hundreds of EMRs out there it would the most suited to the task. In fact, after one presentation, representatives from an aviation software company approached us to ask if we would consider adapting EncounterPRO to serve as a cockpit management program. Given EncounterPRO’s roots we were flattered and intrigued, even if we eventually decided to continue to concentrate solely on ambulatory EMR workflow automation.

My own MS in Industrial Engineering at the University of Illinois, Champaign-Urbana involved a year in both the aviation human factors and health systems engineering programs. (This was by accident. There was a research assistantship available to work on an aviation human factors research project.) Aviation and aerospace medicine intrigued me for a while, but I decided that health care workflow was an even more target rich environment. Ironically, several years later I wrote natural language processing grammars for the Pilot’s Associate project (where I faced the truth of a popular linguistic proverb: All grammars leak.)

I had the enjoyable experience of hanging out with a sizable community of aviation human factors graduate students (both from IE and from other graduate departments such as psychology). That’s where I learned about the Fitts and Hicks laws that I discussed in the Cognitive Psychology of Pediatric EMR Usability and Workflow. I also bumped into an idea that has stuck with me since.

For each of the effects of the normal aging process–

  • vision decline,
  • hearing loss,
  • motor skill diminishment, and
  • cognitive decline

–there are a set of design principles and assistive technologies that address environmental challenges causing similar decreases in skilled performance.


Low light, or a requirement to rely on peripheral vision, can cause similar sorts of performance problems as those associated with vision decline. For example a fighter pilot must keep his or her eye on an opponent, but also monitor fuel and other system status indicators with peripheral vision. The most important displays are large, consistently placed, but do not block high-acuity foveal (central) vision. Cockpit designers often rely on alternative sensory modalities such as sound (buzzers) and touch (vibration) to not overload visual processing.


Similar to mild hearing loss, noisy environments (such as working around jet engines) also make it difficult for the listener to separate signal from noise. Compensatory design and assistive technology involve signal amplification (loud speakers), noise reduction (noise canceling headphones), and alternative sensory modalities (writing pads).

Motor Skill

Diminished motor skill results in increased time to hit a target and increased instances in which the target is missed altogether. So does moving a target and human relative to each other.  In the cockpit, turbulence, evasive maneuvers, or certain in-flight emergencies (such as I studied as a graduate student) cause relative movement between cockpit targets and pilot. Imagine trying to enter data and orders into an EMR while aboard a bucking bronco and you get the idea.  Compensating design makes switches larger and easier to hit, and offloads or postpones as many low-priority tasks as possible.

I am reminded of waiters in a busy well run lunch-time restaurant, like ambulatory pediatrics another classic high-volume, low-margin business. These waiters interact with an order entry touch screen that represents tables and order status located in a narrow passage between the kitchen and the tables. It’s there because waiters have to pass it anyway. Waiters do a “fly by” and enter orders while passing through this narrow passage. They even appear to rely on peripheral vision because they are carrying trays and dodging one another.


Restaurant Point of Sale Management Software

Waiters exhibit a Bernoulli Effect in that they speed up to increase “throughput” between the kitchen and the dining area. However, if they have an order they slow a bit to enter their ID, table, and order while passing by. If they have a large table order, they just slow down a bit more. As they approach they extend their hand, interact as they pass by, and enter the last of their data just as the touch screen passes out of reach behind them. I have seen several miscalculate and have to stop and return and finish an order, but usually they get the timing just right.

(Warning! Brief digression ahead!)

By the way, take a look at this list of restaurant point of sale software features and return on investment (slightly edited to make a point).

“BOOST PRODUCTIVITY Easy To Use Touch Screen Ordering…Accurate and fast communication from…staff to…staff…Intuitively enter orders with customized screens that reflect your…items and common customer [assessments and tasks] Reduce training time for new…staff.

MAXIMIZE [EXAM ROOM] TURNS: Fast Payment Processing…Eliminate manual calculations and multiple entries.

IMPROVE CUSTOMER SERVICE Valuable Time Management…Real-time [patient] status information…Effectively manage [patients] in multiple rooms…Reduce waiting time for customers.

INCREASE PROFITS Efficient Back Office Management…Detailed revenue and productivity reports…Efficiently manage staff with automatic labor costing, scheduling and attendance…Decrease routine management tasks.”


According to the National Restaurant Association’s Restaurant Industry Operations Report 2002, the average restaurant spent a total of 35% of their annual sales on salaries, wages, and benefits. Labor costs are the highest expense. Restaurant automation integrates key business functions in order to maximize efficiency and reduce labor costs.

Most restaurants operate on low profit margins. In fact, the average restaurant keeps less than a nickel in profit for every dollar earned. Furthermore, the restaurant industry has seen modest growth of 1% to 3% annually since 1991. Low profit margins combined with modest growth result in numerous challenges. Restaurant automation offers opportunities to increase revenue and sales per customer.

Sound familiar? While previously touched on, the analogy between running a restaurant and busy pediatric or primary care practice deserves  a future post.

(End of digression.)


Senior Friendly = Everyone Friendly = Pediatrician (and Primary Care) Friendly.

Many senior-friendly environments feature “Where was I?” strategically placed memory cues. Similarly, everyone-friendly technology helps us all manage tasks and remind us of what we were doing next. High cognitive load plus high mental effort plus unpredictable arrival of competing tasks plus further distractions equals forgetfulness.  Folks fortunate enough to be at the peak of their mental powers just take a bit more environmental duress to cause them to make the same sorts of mistakes that we all make when we get older.

If you’ve read any of my previous posts I suspect you know where I am going with this. EMR workflow systems show how principles of senior friendliness can result in an EMR that is friendly to anyone operating under less than optimal conditions.

Peripheral Vision

Ideally, a primary care physician (or most physicians dealing with a conscious patient for that matter) should be able to chart data and orders while giving a patient his or her full attention. Consider this quote from What Makes a Great Pediatric EHR to see what I mean:

“One Georgia pediatrician, a winner of the HIMSS Davies Ambulatory Care Award of Excellence for his use of the EncounterPRO EHR, shows his attentiveness using one hand to steady an energetic child and the other hand to enter data and orders out of the corner of his eye, facilitated by large colorful buttons. A workflow engine pushes screens in preprogrammed sequences so he is not distracted by screen-to-screen navigation. His focus remains uninterrupted and attentive to the concerned parent.”

Noise Reduction and Compensation

Pediatric and primary care offices are noisy environments, so instead of having to walk or shout down the hall, tasks automatically forward from user-to-user (consistent with executing process definitions). This compensates for a noisy environment through noise reduction (less conversation about what to do next) and use of alternative sensory modality (sight instead of hearing).

Motor Skill and Cognition

According to this video, a pediatrician can chart a routine encounter in as little as 12 seconds with EncounterPRO EMR Workflow System. What if they’re interrupted? Not only can a pediatrician quickly chart, if they’re interrupted in the midst of charting an encounter, EncounterPRO provides visual memory cues (via the Office View) to help them to later find and complete the encounter.

If a pediatrician or primary care provider must temporarily step away to perform a higher priority task, they:

  • Touch the “I’ll be back” button and the workflow engine suspends its automated workflow. Colorful information-packed bars represent this suspended workflow in the Office View’s exam rooms.
  • Do something else.
  • Later, notice an Office View service bar in their assigned color.
  • Walk to the indicated exam room.
  • Touch the colored bar (task screen appears).
  • Quickly perform the task by tapping the small number of consistently placed and (sequentially) presented large buttons.
  • Dismiss the screen.
  • Another screen appears if there is another step in the workflow that falls within their responsibility.
  • Eventually perform the final task in the workflow for which they are responsible.
  • Notice another task in the Office View for which they are responsible.
  • Leave to perform that task.

Everyone in the office participates in this basic loop of viewing a set of tasks waiting for them, choosing a high priority task (often the oldest in indicated minutes), and just doing it. There’s an interesting peer pressure effect too. No one sits down while there are tasks in their color visible to others!

While I am not suggesting that a physician can or should literally (as in the case of the previously discussed waiters) chart “on the run.” However, the ability to quickly spot what needs to be done, dash to the right patient, quickly assume and complete their portion of the encounter workflow, and move on in a few seconds is almost that.


Similar to an under-attack fighter, a busy airport control tower, or a hectic lunchtime restaurant, medical practices can be high cognitive load environments (especially during the flu season). All three require multitasking and prioritization in the face of interruption and distraction.

That’s the connection between aviation human factors and an EHR/EMR workflow system’s unusual interface. You probably weren’t expecting a side trip through senior-friendly product design (although I did touch on precisely this topic in my previous post on the Cognitive Psychology of EMR Usability and Workflow). The high-usability EHR/EMR workflow system relies on the same principles that help seniors, jet pilots, and physicians cope with noise, motion, and distraction while focusing on what is most important.

“Cheaper By The Dozen” Efficiency Gurus Meet EMR Workflow Systems–Usability Results

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Last week’s post (A White Paper About EMR Workflow, Usability, and Productivity in Pediatric and Primary Care) was *so* serious, and 5000 words to boot (including the white paper). This post is compensatorily on the lighter side.


A Metaphorical Depiction of an Assistant
Handing a Physician the Right Data or
Order Entry Tool at the Right Time

So, have you ever heard of the movie or the book “Cheaper By The Dozen”?

Whenever I talk about industrial engineering approaches to healthcare in general, or pediatric and primary care in particular, I usually mention Frank and Lillian Gilbreth, Ph.D., the founding father and mother of industrial engineering techniques applied to healthcare. They invented the Therblig (“Gilbreth” backwards–almost), a unit of work.  (The PowerPoint slides I usually use to introduce this topic are below.)


The Gilbreth’s family life was recounted by two of their children in the memoir “Cheaper by the Dozen” (the 1950 movie, not the 2003 version with Steve Martin). They ran their household of twelve children as an experiment in the application of modern efficiency principles (many of which they invented)–hilarity results.

Dr. Gilbreth received the first Ph.D. in Industrial Psychology (from Brown) and was the first woman member of the American Society of Mechanical Engineers and the National Academy of Engineering.

“Lillian Gilbreth is best known for her work to help workers in industry with her classic Time & Motion Studies, which supported work simplification and industrial efficiency. Lillian Gilbreth was one of the first scientists to recognize the effects of stress and lack of sleep on the worker.”  Lillian Gilbreth and Frank Gilbreth – The Birth of Ergonomics

The previous quote uncannily describes both the plight of a physician *and* the positive benefits of an EMR workflow system–stress and lack of sleep versus simplicity and efficiency. Ergonomics is the science of designing the job, equipment, and workplace to fit the worker. Computers didn’t exist when the Gilbreths founded the science of ergonomics, but the direct descendent of ergonomics today is usability. If Frank and Lillian Gilbreth are the founding father and mother of ergonomics, it would not be too much of a metaphorical stretch to say that they are also the founding grandparents of usability.

“Doctors to this day owe a debt to them, since it was Frank who first came up with the idea that surgeons should use a nurse as “a caddy” to hand them their instruments as and when they were needed. Previously surgeons had searched for and fetched their own instruments while operating.” Gurus: Frank and Lillian Gilbreth

The key? Without the surgeon being required to remove his eyes from the task at hand, at the right time and right place the right tool should be passed to the surgeon in its most “usable orientation.” (Patient Safety in Emergency Medicine, page 98) Again, this presages the use of EMR workflow systems to “hand” a physician the right data or order entry tool at the right time and place during a patient encounter.


I usually then move on to review typical topics of industrial engineering study and application–decision science/operations research, human factors and ergonomics, manufacturing and production systems, and quality engineering–and then point out that modern IE departments often have an optional health systems concentration as well. I’ll definitely turn that material into a future post; but here I’d do something more fun: plumb Cheaper By The Dozen for parallels to improving pediatric and primary care workflow systems.

The following are some quotes from 152  reviews of Cheaper By The Dozen on Amazon (many of these charming essays were lovingly written by children: “A review from a 6th grade reader”, “Honors English fifth period!”, “Ross Middle School 6th Grader“, “Sarah from fifth period”):

“How can you afford so many kids?”, a stranger would ask. Frank would say, “They come cheaper by the dozen, I guess.” (Complete review on Amazon, by the way I don’t get a commission from Amazon.)

This book is the story of an unusual family at the turn of the century, with twelve children. The father is an efficiency expert who runs the family like it is a factory assembly line, with everything timed down to the minute. Even the times for bathing are scheduled, so that the household runs smoothly. Mr. Gilbreth practices all of his ideas on how to run an efficient business on his family; they are the guinea pigs for new ideas…Both of the parents were  professionals, as the mom was also a psychologist and industrial engineer. They applied  their professional ideas on raising the 12 kids. (Complete review on Amazon)

The amazing Gilbreth family shares hilarious and heartwarming stories about growing up with parents who basically began motion-study (figuring out how businesses could do things in less time). This is one to read out loud to the kids. They will laugh and laugh…and so will you. :^) (Complete review on Amazon)

When Frank and Lillian Gilbreth married, he said he wanted to have an even dozen children and Lillian was happy to oblige, having six boys and six girls. Frank and Lillian worked as efficiency experts and Frank employed efficiency techniques at home including figuring out how to shave in the quickest amount of time; how to dress as quickly as possible; having everyone in the family get their tonsils removed at the same time; and holding an Assembly Call in which he whistled and timed how long it took the family to gather together…Together they had all kinds of adventures, some on land, some at sea, many of them hilarious. (Complete review on Amazon)

Mr. and Mrs. Gilbreth, experts in motion-studies and industrial efficiency, apply their skills to managing their enormous family. Love, goodwill, and humor spill off the pages. (Complete review on Amazon)

Gilbreth is a father of 12 during the early 1900’s. He is a white collar professional whose specialty is “efficiency”. In order to run this large household smoothly, Gilbreth introduces systems of operation similar to a factory within his home. This book is funny as we watch the children go through their daily grind using Father’s grand plans for organization. I thoroughly enjoyed reading this novel and highly recommend for a quick read. (Complete review on Amazon)

The Gilbreth family of 12 kids, parented by efficiency experts Lillian and Frank, were a bit eccentric and very funny…The Gilbreths were actually serious innovators of efficiency for the new factory assembly lines, figuring out the number of movements needed to complete a task and establishing a unit of work movement called the Therblig. (Complete review from Amazon)

This is a story about family. It is funny in a gentle way. Family values, respect , and good-natured fun are featured in this period piece. Both mother and father are efficiency experts who believe that having a dozen children is most efficient. The humor comes from the situation of having twelve children and all that it entails. (Complete review on Amazon)

What I really liked about it was how they were always trying to find new ways to make their lives more efficient, by doing two things at once, like brushing their teeth while learning a language or shaving with two razors. (Complete review on Amazon)

A famous effiency expert who believes a family can be run just like a factory, has charts all over the house so that he can make sure that chores are being done. He has the older children in charge of the younger children to learn “responsibility.” (Complete review on Amazon)

I found this charming story to be captivating, motivational, heartwarming, and humorous. The story was coiled around the father of twelve children, Frank Gilbreth Sr., who was in the business of “motion study” which he was very good at. Motion study was said to be finding the way to make-work quicker and more efficient. (Complete review on Amazon)

A reporter asked Frank Gilbreth Sr. why he wanted to save time and what he used his spare time for…This is what Frank Gilbreth Sr. said in reply to the reporter’s question: “For work, if you love that best…For education, for beauty, for art, for pleasure…For mumblety-peg, if that’s where your heart lies.” (Complete review on Amazon)

Some final thoughts:

  1. As an only child who grew up on a farm, I’m a bit envious how much fun a large family apparently can be.
  2. The emotional tenor and potential for chaos inherent to a large family reminds me of just about a every pediatric clinic I’ve experienced.
  3. The efforts to impose order and efficiency reminds me of the effects of a pediatric EMR workflow system: “everything timed down to the minute,” “how businesses [can] do things in less time,” “how to do [X] in the quickest amount of time”, “always trying to find new ways to make their lives more efficient,” “doing two things at once,” “finding the way to make work quicker and more efficient,” as well as the systematic delegation of responsibility amongst family members.
  4. If Frank and Lillian Gilbreth were alive today, I believe they would be early enthusiastic proponents of EMR workflow systems, which achieve through workflow automation many of the same goals emphasized in Cheaper By The Dozen. In fact, just as I noted in an earlier post, an EMR workflow system is similar by analogy to a hyper-competent operating room nurse who automatically hands you the right data entry or order entry tool at the right time and place in the patient encounter.
  5. The question the reporter asked Frank Gilbreth, “why he wanted to save time and what he used his spare time for” reminds me of a question we sometimes ask potential customers, “If you had more time, what would you do with it? See more patients? Spend more time with each patient? Go home on time? Some combination? Something else?”

“For work, if you love that best…
For education, for beauty, for art, for pleasure…
For mumblety-peg, if that’s where your heart lies.”