I haven’t met a physician yet, who likes EMR software

I only have anecdotal evidence, but every physician I talk to, hates the EMR software he has to deal with.

Ye old Enterprise IT

One particularly tech savvy young resident in an area hospital, says, “… too many clicks, too many clicks“. These are folks that live in their iPhones and iPads every spare moment they have.

As he did book-keeping on his laptop, I peaked over his shoulder at the EMR program he was using.  Also, a couple of months ago, I had occasion to spend a few days at Johns Hopkins, helping take care of a family member, and I took every chance to watch the staff at work at their monitors, which now seem to be stashed into every available corner (each patient’s room had a desktop, monitor, keyboard, and mouse).  I was a little taken aback to see that they were all using Windows desktop applications.  Seen through eyes drunk on modern touch-screen mobile devices, these apps look old-fashioned – poor, tired, windows, boxes, lists and buttons, huddled together in an unappealing jumble.

My doctor friend said his EMR was cumbersome to use, and it took too long to enter all the data that he is prompted for.  He seemed to unconsciously separate information that is vital to patient care, from information that is just “for billing“. Often, he enters only the patient care information that he thinks is necessary, and ignores what he called, “fluff“.

The word “fluff” struck a chord.  Design for mobile first.  That forces you to identify the “fluff“, and drop it.

Essentially, what I saw was classic Enterprise IT interfaces.  They serve some bare business purpose, with little thought to ease of use.  Users, doctors, and nurses, in the midst of their high-stress workdays, just deal with it, because, well, they have to.

There were more tell-tale signs of Enterprise IT.

"Yea, they improve things, but everybody hates the changes. You 
manage to learn one thing, and then they make you learn something 
new all over again."
"They never ask the doctors.  They try to keep us away from what 
they are doing.   They build something and show it to us, and it 
is not great, but then it is too late to change anything."

Impenetrable domain knowledge

The doctor is looking at lab results.  He sees that haemoglobin is low.   In that situation he is taught to then look at past iron levels, and vitamin levels, which are results of other tests.   In the interface he showed me, the iron levels, and vitamin levels were hard to find.  The lab results were a long Excel like table, and he had to scroll far and wide to find them.  They were not close to the haemoglobin levels.  The interface was not smart enough to offer the iron levels and vitamin levels when it detects that the haemoglobin is low. The doctor said he sometimes surrenders to fatigue and irritation and simply orders the tests for iron levels and vitamin levels again.   Of course that is duplicated effort for someone, not to mention a wasted expense.

The business analyst who modeled the diagnostic processes obviously did not know how medical personnel are expected to react to low haemoglobin.    The UI designer did not know that a relationship exists between low haemoglobin, and iron, and vitamin levels.   The interface they built does not reflect that knowledge.  The EMR software did not make the physician’s job easier.  In fact, it made the whole process more inefficient, and wasteful.

There must be so many other little use-cases like this.  I imagine the patient care domain is vast, varied, and complex.   A doctor spends years acquiring all that training, and knowledge.   How can you expect a business analyst, or UI designer to absorb all that information?   Even in the best of circumstances, there are so many ways for domain knowledge to get lost in the translation, from business user through business analyst, to system designer, and finally to the developer.  I imagine that this exercise is even more error-prone in a complex and information-heavy field like patient care.

Are we barking up entirely the wrong tree?  Is it a fool’s errand to try to model the patient care domain in order to produce a structured interface that makes the doctor’s job easier?


A simple-minded EMR

I wonder if something like this would be a viable EMR system?

A universal key

You must be able to uniquely identify a patient, a human being.   In other words, you need a universal key for their records, which you can apply at any health-care organization they are visiting.  Say, fingerprints.  Would that work?

A simple collection of documents

Medical records themselves are just a collection of documents.  They can be anything at all – plain text, HTML, WORD, EXCEL, PDF, audio, photos, video, etc.  Each provider simply creates whatever records makes them happy, in any format at all.

Each document is characterized by very simple, non-medical meta-data.

  • Who created them?
  • When were they created?
  • etc.

The documents are all stored together against that universal key.   You have the patient’s fingerprint, you have her records.


You need the ability to search through a patient’s medical records – the collection of heterogenous documents. You must be able to return results ranked by relevance.


You must have the ability to simply transfer the records of a particular person between providers.  And even to the patient herself.   This is a simple transfer, because there is little structure to speak of.   It could be as simple as an email with attachments.

Start Minimal

That’s it.   There is your minimal, but possibly complete, EMR.  In capability, it probably matches what folks are able to do with paper records, with added sugar due to the fact that the records are native citizens of the digital world.

The system is simple enough that it can be quickly adopted by organizations.  This is what every institution must be able to do, off the blocks.  No complex analysis effort.   No errors that are introduced simply by the act of creating the new system.

And build on it

Once the system is on-line, slowly build on it.

  • Improve identity tracking, if necessary.
  • Improve entry, generation, and visualization of data.   As we saw above, this means applying knowledge that only physicians have.   Business analysis must come directly from the physicians.   Work on one specialty at a time.  Work on one disease at a time.  Or something like that.
  • Improve search.  Which is really ‘data analysis‘ aka ‘analytics‘ aka ‘big data‘.
  • Improve data storage, and data transfer.

And so on.


Many Whys

So why are EMR systems not as simple as the one described above?

Are there considerations that I still have not learned about?

Why is there so much structure, which is hard to get right, and much of it un-intuitive to physicians?   Are these related to ‘accountability‘, and ‘billing‘?

I mentioned HL7 standards, and SNOMED taxonomies to a couple of young doctors – a resident, and a fellow.  They had never heard of them.  This is medical knowledge that software engineers are basing EMR software on, and doctors have little knowledge of them?  I was about to sign up for an expensive week-long seminar on HL7.   Is that a waste?   What is going on?

I went to a meet-up of the local Health 2.0 chapter.  Folks spoke with enthusiasm about many things, but EMR systems did not come up at all.

There seem to be a lot of startups doing healthcare related work in Pittsburgh.   However, everybody I met is working on devices, and solutions for use by individuals to get control of their personal health .  No one said anything about making a doctor’s day to day work easier, and more effective.

There is something interesting going on here.   Are enterprise concerns, like EMR, simply  un-cool?  Or are they considered a done deal?   Is it too late, and well-nigh impossible, to enter the field now, and improve on matters?











What use is knowledge that I cannot name?

It turns out that I have done information architecture for some time now, but I never knew it.

A young acquaintance is learning HTML, CSS and such.  I gave him Steve Krug’s classic handbook, Don’t Make Me Think.  My young friend banged through the book in a day, and his cup running over, started going on about this, that, and the other, including at one point, ‘tabbed pages‘.  After some confusion, I realized he was referring to a web page whose content was organized with tabs,

A web page organized with tabs

A web page organized with tabs


rather than the tabs that most modern browsers offer.

Tabs in a browser

Tabbed Browser windows

Unaccountably, the ‘tabbed pages’ triggered a thought that had not occurred to me before – the ‘tabbed page’ represents at least three different kinds of knowledge.

The users’ needs

Tabs in a web page exist for a reason.  They serve a purpose.   Someone devised them to solve a problem.  What is that problem?

Shoe store

A user is at shopping site.  Say, a shoe store.

The store sells stuff that you can classify in categories that are familiar to, and expected by the user – Men, Women, Children, Casual, Formal, Outdoor, etc.   Each category of shoes has more items than you can fit in the real estate available on a single web page.

The shopper must be able to peruse any category that she is interested in.   Further, regardless of where she is in the site, the shopper must be able to switch to any other category of shoes.

Farm insurance policy

You own a large farm.  You have an insurance policy for the farm, which includes many individual coverages.  You have had the policy at the same insurer for several years.   You want to log in to your insurance company’s web site, and see all available information on your farm policy.

An insurance policy is characterized by many different kinds of information.

  • Demographic information about the policy’s owner – name, address, age, marital and employment status, etc.
  • The various coverages included in the policy – Livestock, limits of the coverage, deductible associated with the coverage; outdoor buildings, limits of the coverage, deductible associated with this coverage; coverage on machinery; coverage against crop failure; and it can go on and on.
  • Historical data – the policy as it existed in past years (the industry refers to that as ‘terms’)
  • Billing history
  • Documents associated with the policy – signed agreements, photos, letters that went between customer and insurer, etc.

You cannot fit all of this information into a single screen.   You must clearly indicate what types of information are available for a policy.  Finally you must allow the user to pull up and view any type of information, at any point in her interaction with the web site.

Someone must know

Someone must know the data you are presenting.   What is this data’s place, and purpose in the world as we know it?  Can we break the data down into coherent parts?  How might the parts be related to each other?  How do you refer to the various slices, and components of the data?

Someone must know the needs of the user vis-a-vis that data.   How does the user understand the data?  What is her mental map of the data?  How does she categorize the data?  What names and labels does she use to refer to the data?  How does she think the various pieces of the data are related to each to other?  What exactly is the user interested in viewing?   What processing might she want to trigger on the data?

What do you call this knowledge?

I always thought of this knowledge as ‘business analysis‘. I suspect that most folks I have worked with, none of them trained in the magic arts of user interface design, would also think of this as ‘business analysis‘.

However, I am learning lately that this particular sliver of the business might be known as ‘information architecture‘.  I am not sure. Does it matter what it is called?


Presentation solutions

Now you understand the data that you have to present.   You also understand the user’s expectations regarding the data.   Can you devise ways of presenting the data such that the user’s needs are served?

You do not know how to write computer programs.  You know color, shape, image, typography, and layout.  You know how people react to these visual elements.   You can communicate with people using just those tools.   You know how to convey information, suggest actions, and create a virtual environment on the computer screen, which makes a user feel safe, competent, and perhaps even happy.

You are able to use the expertise I described above and design many different ways to satisfy the needs documented by the ‘information architecture‘.  Of these various alternatives, ‘tabbed pages‘ are just one.  Here are some others.


Drop-down for choosing between categories

Drop-down for choosing between categories



An index, and a tree of links

An index, and a tree of links


tag cloud

A tag cloud


You also probably know how to present these alternatives to users, and test their use of them to determine what works best.

Once one of these alternatives, perhaps even tabbed pages, is chosen, you ask computer programmers to construct the interface.

What do you call this knowledge?

So what do people call this expertise?   I hear several terms, all of which seem related.

  • Graphic design
  • Visual design
  • Interaction design
  • Human computer interaction
  • Anything else?

Do they all refer to the same questions, and answers?  Is there an overlap?   Does it matter?

Is it possible to be good at one, and not the other?  Can you be a good graphic designer, but a poor visual designer?  Could you be an an expert on human computer interaction without being a good visual designer?  Or could you be good visual designer but know little about interaction design?  The last does seem plausible.  Mostly, all of this seems a little bit nuts; another case of words getting in the way of meaning.

In layman’s (that would be me) terms, this expertise simply seems to be what falls in between knowledge of the business – data, processes, and users, on the one hand, and the ability to construct the interface, on the other.   These folks design an interface in response to the business knowledge that the ‘business analysts’, or ‘information architects’ provide, and the ‘programmers’ (the construction workers of the digital world) tell the designers what they are able to slap together.

Constructing a solution

Finally, we have the field of knowledge that I am able to grasp effortlessly.   Given a blueprint of the interface, someone has to make it flesh.

You use languages and technologies like HTML, CSS, Javascript.   You can also choose some server-side poison like ASP, JSP, XUL, and so on.   The more you are cognizant of the other two kinds of knowledge, the more effective your construction will be.  However, you often know little other than the construction tools.

What is this knowledge called?

I think this is what many people call ‘web development‘.  Often, a web developer is almost always someone with only knowledge of  ‘construction‘.


Why does any of this matter?

If you are starting out, and getting a kick out of creating web-sites, are you able to figure out which of the three types of work is giving you the high?

Just as important, are you able to tell which of the three areas you have a facility for?

  1. Do you like the rigorous analysis, and the emphasis on precision in language, which seems the central characteristic of ‘information architecture‘?
  2. Do you have a gift for communicating visually, without which you can’t do well at the ‘presentation design‘ part of the work?
  3. Or do you have a gift for nuts and bolts detail, and are able to methodically, and relentlessly concentrate on a job till it is done?  This is what construction requires – stamina.

The question is just as relevant for someone like me, who has been programming for a while, and has lately developed an interest in something that I know is not exactly programming, but I don’t know what to call it.  The best thing I can think of is – you know, that thing that Apple does so well.   Design?  User experience design?  Usability?  What?  I have never thought of myself as a creative person.  What?

For the record, I think my strengths might be (1), and (3).   I enjoy, and obsess over (2), but I don’t have a gift for it.  I think.   As the man said, “it is a puzzlement”.