Electronic Health Records: ”A disease in need of a cure”, says NY Times

In most industries, automation leads to increased efficiency, even employee layoffs. In health care, it seems, the computer has created the need for an extra human in the exam room.
A Busy Doctor’s Right Hand, Ever Ready to Type (Jan 12, 2014)

NY Times article about personal scribes helping doctors to handle the growing demands of e-health systemsThis New York Times article is a devastating reality-check of the state of health care in advanced countries, which have invested heavily in electronic health records (EHRs) and related systems.

Claims – often from both government and IT companies – that the technology would increase efficiency have now been refuted again and again. Instead, the systems lead to increased stress and workplace health problems. “Chronically exhausted and feeling enslaved to the computer”, Dr. Jennifer Sewing describes her situation.

Electronic health records have become a disease in need of a cure,” NY Times concludes.

The somewhat paradoxical solution is to give doctors a personal scribe, to handle the systems. Nearly 10,000 scribes are said to be working in hospitals and medical practices around the US, with demand rising quickly.
The personal scribe or assistant feels like a life-saving solution for the burdened doctors. Dr. Sewing, a family medicine practitioner, “used to spend late nights at her computer finishing electronic patient charts”. Now, she can relax and get a good night’s sleep.

But is this really sustainable? Health care will then be faced with increasing costs for both supposedly time-consuming technology and for more staff.

A change has got to come: More usable software – but also a huge reduction in the clerical, administrative load that, in fact, the systems have helped to produce.

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Featuritis vs. the Happy User Peak

Not new, but Kathy Sierra’s Featuritis-curve is too good to not repeat at the beginning of the year.

The Featuritis Curve by Kathy Sierra

To show a real-life example, from 2013: this interface from an enterprise system has 11 menus, 14 tabs, 9 buttons, around 20 icons with other functions, some scroll bars, more than 50 fields (just under this menu/tab-combination). Menus and tabs are even repeated in a left-hand navigation.

Feature-rich screenshot

Although many of the functions may be necessary, even vital, the design is a hopeless clutter that puts a completely unnecessary strain on the user’s cognitive resources. (In the most recent version of the system I saw, the number of tabs had increased to 20.)

See also: “Your stupid system makes me fat!” (Dec 23, 2013).

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“Your stupid system makes me fat!”

One of my points is that stupid IT systems put a heavy cognitive load on the users. Cognitive processing – aka ”to have to think” – is actually hard work. We can see it in rising levels of stress and “workplace fatigue” – but in fact, also in experiments.

The brain’s main fuel is sugar. Kathy Sierra at Serious Pony tells us about an experiment where half the participants were asked to memorize seven-digit numbers, and the other half to memorize two-digit numbers. Afterwards, they were offered a choice of snacks.

The participants who memorized the seven-digit number were nearly 50% more likely than the other group to choose cake over fruit.

Complicated systems make you fat – from Serious Pony

It turned out, seven-number memorizers were much more likely to choose cake than the two-number memorizers (who preferred fruit).

In fact, I’ve observed that exact task performed many times a day while studying actual people at work: memorizing and trying to recall long, complicated passwords. Or having to memorize a social security number from one system, and entering it in another.

Kathy comments:

”If your app is confusing and your tech support / FAQ isn’t helpful, you’re drawing down my scarce, precious, cognitive resources. If your app behaves counter-intuitively – even just once – I’ll leak cog resources every time I use it (…)
And when I back away from the screen and walk to the kitchen … Your app makes me fat.”
(Your app makes me fat. Serious Pony, 24 July 2013)

More Kathy Sierra goodness: Featuritis vs. the Happy User Peak (Jan 1, 2014).

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Coming: Keynote at Intranets2014

I am deeply honoured to have been invited to give a keynote at the Intranets2014 conference in Sydney, Australia, in May 2014. And of course very excited, too!

Thanks to the lovely people at Step Two Designs, who organises the conference. You should know that Step Two is widely regarded as the world’s foremost intranet experts. Check out their excellent books, for example.

The term “intranet” is increasingly giving way to the term “digital workplace”. Though not perfect, it pretty well sums up how today’s workplaces are immersed in digital technology.

But while most of the new digital services and products that we can enjoy at home, as consumers, are smooth and pleasant, many of the systems in the workplace are still ugly, arcane and cumbersome to work with. And the gap is actually widening. But why? And what are the consequences? And what can we do about it? I’ll try to address some of those questions in the keynote.

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Who SUNCS at your office? Probably everyone.

So you’ve heard about BYOD. But not about SUNCS. Yet it is probably more widespread; odds are that you have more than one co-worker in your office that SUNCS. It is rarely acknowledged – but in fact, it permeates many organizations.

SUNCS stands for Secretly Using Non-Corporate Software – because the usability of systems inside corporations is far behind what is available to us as consumers.

In 2012, for example, it transpired that officials at the Swedish State Department regularly used Gmail or Hotmail (translated) for communication with Swedish embassies, diplomats and other agencies (translated) – and that even the Secretary of State himself, Mr. Carl Bildt, did it.

Portrait of Carl Bildt, with text Carl Bildt SUNCS at workThrough his press secretary, Mr. Bildt casually remarked that the official e-mail system of the Government was so hard to use that he didn’t bother with it but for the most sensitive documents and messages (a bit in English here).

The unique thing was not the practice in itself, nor that it happened in the highest political circles. Having done some work for the government as a consultant, I’ve found SUNCS at many levels. Unique, though, was that it was so matter-of-factly admitted, by the highest boss as well. (Probably Carl Bildt, famous for being a ”Teflon politician”, was the only one who could have gotten away with it.)

Secretly Using Non-Corporate Software, or SUNCS, is in fact widespread in most organizations. Some typical examples:

  • Although Sharepoint might be the prescribed company platform for storing documents, it is so hard to find anything on it, that colleagues will share documents via Dropbox instead.
  • While there might be a budget forecasting system in the org, in reality people will use Excel – afterwards spending time adapting the result so it fits in the awkward format of the ”official” software.
  • And instead of the cumbersome corporate project planning system, people will book meetings with services like Doodle and organize collaboration through brilliant and simple, easy-to-use apps like Trello.

SUNCS is probably much bigger than BYOD (Bring Your Own Device), since you can do it without attracting the immediate attention of the IT department – or co-workers. It is often known to everyone, though, but not talked openly about.

And by no means is SUNCS unique to Sweden. In August 2013, it was discovered that doctors at the Oregon Health Sciences University stored information about several thousand patients on Google Drive – and had been doing so for the past two years.

So what is the problem when someone SUNCS? In some cases, there might be a security concern when external or cloud-based services are used for sensitive information. (At the Swedish State Department, eventually someone accidentally did send secret documents through the wrong channel.) On the other hand, in the light of recent events, even the security of ”official” services is seriously in doubt.

To me, the most interesting thing with SUNCS is that it points at ”the elephant in the room” that no one speaks openly about: the poor usability of enterprise systems. The co-worker that SUNCS is probably just trying to do her job in the best possible way, avoiding time-wasting struggles with awkward, outdated and inefficient systems.

About the Oregon case, David Do, who is both an MD and an agile software developer, writes that

”… this incident pretty much highlights the sorry state of information systems within the hospital and the unfulfilled need by physicians for tools that facilitate workflow and patient care.”

What the Recent Data Breach Says About the State of Health IT
(The Health Care Blog, Aug 11, 2013)

Doctors (in Oregon and elsewhere) need a short summary of each patient’s health and treatment, David Do explains. But the Electronic Medical Record system used does not have a good way to store information in that format (instead, EMRs are often so full of detail that vital information is hidden). Additionally, a doctor has no way of editing a summary in real-time to communicate with co-workers what still needs to be done – other than Google Drive. (Do read the comments to David’s piece, too – they’re very clarifying about the current state of most software.)

The extent to which people SUNCS shows that the investment the company did in whatever system people are supposed to use, is wasted.

And if people first use non-corporate software to get their job done, and then must ”adapt and insert” their work into the official system, every task takes twice the time – adding to inefficiency.

SUNCS was here before BYOD, and is probably bigger. And unless we take on the problems with enterprise software that sucks, it will grow even bigger. An older generation of workers toiled under their systems, not aware that there were simpler, more effective ways of accomplishing the same task. A younger generation will without doubt compare the awkward user experiences with services that they’re used to – Facebook, Dropbox, Gmail, Spotify, and many others – that they have access to as consumers, and simply not put up with lagging enterprise software.

The gap between enterprise and consumer software is widening. Enterprise software needs to catch up. We can, and must, demand consumer-grade usability at work, too.

* * *

Related reading: The doctor that rocks the mouse
What’s the waiter doing with the computer screen?

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This goes to eleven: the bus driver’s many interfaces

eleven devices, with eleven screens, around the bus driver's seat
I snapped this pic in the transfer bus from central Stockholm to the ferry terminal (click to see a larger image).
I counted to ten different screens around the driver’s seat. Nine were special devices, mounted to the dashboard: the GPS, radio, ticket machine, credit card terminal, communication system, route and timetable status tracker … An eleventh device – a reader for travel cards – was a little bit to the right. It’s primarily used by the passengers, but I saw the driver helping some passengers interact with that too.

You immediately see that every screen is different: full four-color LED, black and white, monochrome green, a single line of LCD characters. Each device has a its own control mechanisms – physical buttons, or virtual buttons on a touch screen, or both.

So the driver has to interact with each device/system in a different way. There’s obviously a lot to learn and remember for the driver here.

Bus driver interactiong with the devices

As Kadir at envision observed recently:

”Just a short while ago it was normal for people to have very few interactions with machines throughout the day. They used them at their jobs, and they were properly instructed. If the machine had its quirks, people knew how to work around them, they adapted to the machine, no problem. Fast forward to today and the world has changed. We are interacting with machines all day long, at home, when driving, parking, getting a snack, buying groceries. You are using a machine to read this text and depending on your definition of machine, you probably have more than a hundred of them working on the machine you are reading this text with. People adapting to machines was manageable when they operated one of them every day. Today that’s not an option anymore. That’s why User Experience Design as a field is rising in importance.”
(Why Bad User Experience Will Kill Your Product, May 30, 2013. My emphasis added.)

I’d just add one thing to that: unfortunately, it’s not at all sure that a product with bad UX will be killed – if it’s something we have to use at work. The bus driver can’t really refuse using any of these devices, or replace it – even if hates it. And he/she often has little influence over the company’s decision what system to use.

This is the digital workplace of today. Whether you’re in a bus, in the office, in a shop … we all have to master a multitude of systems.

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”Workplace Tetris”

Figure trying to catch falling Tetris blocks with text like CRM, ERP, CMS, Word etc
Fun metaphor from a great talk by @oscarberg of The Content Economy, given at Intranatverk, the intranet conference in Gothenburg (May 21, 2013).

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My keynote from Booster

This is my opening keynote from the great Booster conference in Bergen, Norway earlier this month.
My focus here is to encourage developers to take on the often stupid enterprise systems that we have to use in the workplace. And I also want Scandinavian designers to build upon the heritage and tradition of ”Scandinavian design”, with the democratic design ideals and focus on simplicity, minimalism, functionality. Those guiding principles are exceptionally well suited in a digital world.

Link to Vimeo: Get up from your chair, get digital! – Jonas Söderström’s opening keynote. You can grab the slides for ”Get off that chair, get digital” from Speakerdeck.

And please note! There are lots of other great talks at Booster’s Vimeo site. Do have a look!

Thanks to the Booster team for a truly great conference!

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Just like House – but with real-world IT

Q: How can you tell House, M.D. is fiction?
A: They never have problems with their EMR or other IT systems.

* * *

The following reads just like the script for an episode of House. But it’s for real:

”The man’s sister came to visit him on his second day in the hospital. As she walked into the room she was immediately struck by her brother’s distress.
‘Get me out of here!’ the man shouted from his hospital bed. ‘They are coming to get me. I gotta get out of here!’
His brown eyes darted from side to side as if searching for his would-be attackers. His arms and legs shook with fear. He looked terrified.
For the past few months, the man had been in and out of the hospital, but he had been getting better — at least he had been improving the last time his sister saw him, the week before. She hurried into the bustling hallway and found a nurse. ‘What the hell is going on with my brother?’ she demanded.”

Every month, the Diagnosis column of The New York Times Magazine publishes a real case, and challenges its’ readers to find the correct diagnosis. In Think Like a Doctor: A Confused and Terrified Patient (Feb 7, 2013) the readers learned about a a 55-year-old man well on his way to recovering from a series of illnesses, that suddenly became confused and paranoid.

What’s special is that NYT Magazine provides us with all the actual medical notes, labs and imaging results (with real names omitted). All in all, there are 40 pages that the readers are invited to browse on documentcloud.org (click the image).
bild på fallets medicinska  dokumentation

Having examined the case, several readers found the solution to the mystery: excess levels of the neurotransmitter serotonin, caused by a near-fatal combination of medications from the hospital, from the rehab facility and others.

But what’s interesting to us is the conclusion the column’s writer, M.D. Lisa Sanders, makes when presenting the solution of the case:

”Electronic medical records were supposed to help solve this problem [communication about medications, my note] but it seems they more frequently focus on the kind of information essential for billing so that, whatever problem the patient has, the hospital or facility gets paid. By providing too much information that isn’t medically useful, and not enough that is, electronic medical records are just one more barrier to good health care, one more red herring in the pursuit of a correct diagnosis.
(A Confused and Terrified Patient Solved, NY Times, Feb 8, 2013)

So EMR and EHr software, in its current form, instead made a problem they were supposed to help with more difficult.
”The comments about EMR not helping are certainly on target”, one physician wrote in the comments section. ”Over-medication with dangerous drugs is the other half if the problem. Drugs that are pushed by big pharma, in order to make money. Our docs need to learn to be a little more skeptical before adding more and more meds for every patient they see!” says another.

bild på piller som lagts ut i form av en liten människofigur

Avoiding unwanted drug interactions is now a main selling point (pushed by IT companies) for introducing even more IT systems in health care. Companies typically claim that harmful combinations of medications will be detected, auto-magically.
This might sound good at first. But so far, the IT industry has not really made good on many promises of fantastic effects of their IT health care systems. Plus, to me more IT would be an expensive way of not fixing what is actually the problem: over-medication. So first we pay money to Big Pharma for too many pills; then more money to Big IT for fixing the symptoms (and conserving the problem).

But what about the patient, then? Well, like in a good episode of House, he recovered and is neither depressed or distressed any more.
The health care sector, though is still in distress. That’s depressing.

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Hey, startups: bad enterprise software is there for you to fix

Yongfook, entrepreneur based in Singapore, encourages startups to take on the challenges of enterprise software:

”Every day, hundreds of millions of people go to work and hate the piece of shit software they have to use to perform their jobs.

Every day, thousands of startups are trying to make it easier for people to share 6-second video clips or bookmark photos of cats.

There is a world of enterprise software companies that modern startups are completely oblivious to. These enterprise software companies are making millions of dollars building the kind of technology solutions that the average startup would laugh at. It’s time this changed.
Enterprise

But yongfook’s most important point is this:

”As a startup, your primary goal is to survive. How long until you break even? B2C makes money at scale and through experimenting with different business models – it’s not for the faint-hearted or the low-of-funds.

Your payday will come much sooner and more predictably if you focus on fixing one of the infinite problems that businesses have.
Big, medium, small companies – take your pick.
They are all riddled with problems to solve.

And indeed – when you, for example, find that Springtime’s list of Top 10 business ideas & opportunities for 2013 puts a coathanger for fashion stores that displays the number of Facebook likes for that item at the top of the list, you sort of think – surely we can do better than that?

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