Healthcare Design Thinking and Usability Need Engineering and Workflow

[Thank you to @HealthStandards and @uuability for hosting this week’s #HITsm tweetchat on Usability Gaps in Health IT and prompting this blog post!]

Usability and design thinking are currently hot topics in health IT. They should be. In fact, they should have been for a long time. However, contrarian that I am, I have a bone to pick.


But first, my bona fides. I started out as an engineering student, where I took not just traditional engineering courses, but courses in systems and engineering design. I transferred around a lot but eventually got a masters degree in Industrial Engineering, where I focused on human factors and workflow. One of my advisors wrote the first textbook on human-centered design.

The origin of design thinking is attributed to Herbert Simon’s seminal book The Sciences of the Artificial. I attended Simon’s lectures at Carnegie Mellon years ago (here is a blog post about how his ideas influenced me). I’ve talked design with Don Norman (and written about his mixed feelings toward user-centered design).

Over the years I’ve designed (and written code for) EHR software still in use today, as well as designed or “debugged” innumerable healthcare workflows relying on workflow technology.

The bone I have to pick? Design thinking and usability engineering don’t have enough engineering or workflow substance to be the success they might otherwise become. I am not alone in this assessment (Engineering as a Driving Force Behind the Design Thinking Movement).

One does not have to have an engineering degree to design usable products and systems. However, I believe, you do have to be able to do what engineers do — it is in fact intrinsic to our self identity — build stuff! I was an industrial engineer (now called systems engineering in healthcare), so I built workflows, not cool interactive robots like my mechanical and electrical engineer cousins. However, technology and society have so evolved since then that almost anyone can build stuff today, even cool interactive robots. So much so, that now, I too, build robots, using 3D printers, microprocessors, sensors, actuators, and software.

Users need to make the systems they use. In other words, users need to become creators, or Makers in popular parlance. In healthcare and health IT, this means designing, tweaking, and improving the workflow in which they are embedded.

But engineers can’t build something out of nothing using nothing. Engineers need tools with which and platforms on which to create. This is why I am a proponent of workflow technology. If you know your workflow, and you know how to use a computer, but are not yourself a programmer, then you can design your own health IT application workflow… if … health IT applications are themselves built on workflow platforms. Today these systems have various names, process-aware information systems, business process management, and case management systems. But many other IT platforms currently diffusing into healthcare and health IT also embed the most important characteristics of a process-aware information system, some sort of representation or model of work or workflow, plus some sort of engine to interpret the model. It is often called a workflow or process orchestration engine. Similar, by analogy, to how a software language interpreter interprets lines of code, a workflow engine interprets a description of workflow, to drive health IT software application behavior.

Given the above context (bona fides, plus philosophy and tutorial) here are my answers to this week’s #HITsm questions regarding health IT usability.

Topic 1: Why is usability in healthcare so important? #HITsm

Usability is important because safe, efficient, effective, satisfying workflows are important.

Topic 2: What are some common myths about usability and UX in HealthIT? #HITsm

The number one usability myth has to do with direction of causality. Systems don’t have good workflow because they are usable. They are usable because they have good workflow.

The number two usability myth is adding usability experts to workflow-oblivious software (read, “process-unaware”) can dramatically improve usability of that software. If you can’t change the workflow you can’t make it more usable (at least not dramatically so). There’s a major health IT vendor out there that proclaims their software is usable because they employ 300 usability professionals. Wow! They need 300 usability professionals… I wonder why? Again, please consult myth number one. Usability does not create workflow. Great workflow creates usability.

The number three usability myth is great workflow can be achieved without workflow technology. In other industry when there is a problem, say, pollution, you often see technology to fix or manage the problem named after the problem, as in pollution technology. Healthcare has a workflow problem. It requires workflow technology to fix or at least manage.

Topic 3: Has the ONC “Safety-enhanced Design” requirements helped or hurt the Usability of EHRs? #HITsm

Top-down usability certification hasn’t made much difference because it cannot make much difference, without the underlying health IT software in use become much more automatic, transparent, flexible, and improvable, in a workflow sense. Usability can’t cause these things. Usability is caused by these things. Unless and until health IT moves to more process-aware workflow platforms (which, BTW, is happening, though not fast enough), these sorts of efforts are doomed to frustrate all involved.

Topic 4: What are some additional areas (gaps) in usability of EHRs? #HITsm

Lack of use of workflow thinking and workflow technology.

Topic 5: Medical mistakes are the 3rd largest killer in the USA. What can we do to stop usability issues from killing our fellow citizens?#HITsm

Adopt more workflow technology, so the underlying software can be improved through a variety of means, including usability engineering techniques. See my post on patient safety and process-aware IT.

Thank you to both @HealthStandards and @uuability for hosting this weeks #HITsm chat, and giving me this opportunity to gnaw away at some favorite ideas!

P.S. Oh, by the way, some of the leading figures in the design thinking movement agree with me!


@wareFLO On Periscope!


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