Fitts’s Law: “The time required to rapidly move to a target area is a function of the distance to and the size of the target.”
Hick’s Law: “The more choices you have to choose from, the longer it takes for you to make a decision.”
Applied to pediatric and primary care EMR user interfaces these psychological laws translate into “lots of small buttons all over the place are incredibly time consuming, frustrating, and error prone.” This is why the EncounterPRO-OS Pediatric EMR Workflow System has just a few large consistently placed buttons on each screen.
Which "Targets" Can You Hit More Quickly
and Accurately in Rapid Succession?
How, you ask, can EncounterPRO-OS present enough buttons to a pediatrician so that they can enter all the data and orders that they need? Instead of just a few big screens containing many small buttons and checkboxes and so on, we spread larger buttons (and no checkboxes, not a one) across many screens. How, you ask, are you expected to navigate to the right screen at the right time in order to click on the right button? For each specific situation (well child visit, sick child visit, vaccination, etc.) EncounterPRO-OS presents the right screens in the right sequence back to you in a way that mirrors the natural order of the tasks you need to accomplish.
If the screens do not present themselves in a manner that is consistent with your preferences, they can be configured to do so—either by you or by a third-party EncounterPRO-OS partner. That is what a workflow system does (among many other valuable services). In comparison to traditional "hunt & peck" pediatric EMRs, the EncounterPRO-OS Pediatric EMR Workflow System is an “anticipatory EMR” because, like a good OR nurse, it anticipates what you want to do next and hands you the right data input or order entry tool to accomplish it quickly and without error.
Traditional EMRs Versus EMR Workflow Systems
The EncounterPRO EMR Workflow System pioneered usable pediatric EMR workflow. Period.
In 1991 we wrote in the Journal of Medical Practice Management (reprinted here, page 11):
The combination of structured data entry, workflow automation, and screens designed for touch screen interaction optimally reduces inherent tradeoffs between information utility and system usability on one hand, and speed and accuracy of data entry on the other. Successful application of touch screen technology requires that only a few, but necessary, selectable items be presented to the user in each screen. Moreover, workflow, by reducing cognitive work of navigating a complex system, makes such structured data entry more usable.
In 2004 we wrote in the Proceedings of MedInfo in San Francisco (the top international medical informatics conference):
EHR workflow management systems are more usable than EHRs without workflow management capability. Consider these usability principles: naturalness, consistency, relevance, supportiveness, and flexibility. EHR WfMSs more naturally match the task structure of a physician’s office through execution of workflow definitions. They more consistently reinforce user expectations. Over time this leads to highly automated and interleaved team behavior. On a screen-by-screen basis, users encounter more relevant data and order entry options. An EHR WfMS tracks pending tasks—which patients are waiting where, how long, for what, and who is responsible—and this data can be used to support a continually updated shared mental model among users. Finally, to the degree to which an EHR WfMS is not natural, consistent, relevant, and supportive, the underlying flexibility of the WfMS can be used to mold workflow system behavior until it becomes natural, consistent, relevant, and supportive.
The EncounterPRO-OS Pediatric EMR Workflow System was one of the first successful examples of clinical groupware. Its clinical groupware functionality "leads to highly automated and interleaved team behavior" and "support[s] a continually updated shared mental model among users."
And in 2005 we presented at, and expanded on this subject in the proceedings of, the HIMSS conference in Dallas (the following is adapted from that paper):
Usability is “the effectiveness, efficiency, and satisfaction with which specified users achieve specified goals in particular environments.” However, in the case of pediatric EMR workflow systems, usability must be construed not only relative to single users, but also with respect to the entire team of patients, pediatricians, and pediatric staff who work together for common goals. One might rephrase this definition of usability to become the effectiveness, efficiency, and satisfaction with which teams of users achieve collections of goals in complex social environments.
EncounterPRO-OS Pediatric EMR Workflow System is "Clinical Groupware for Pediatric Practice." It is EncounterPRO-OS's emphasis on the entire team, not just the individual user, which makes EncounterPRO-OS different from traditional EMR closed source "singleware": Our definition of EMR usability is indeed "the effectiveness, efficiency, and satisfaction with which teams of users achieve collections of goals in complex social environments." By the way, just because a traditional EMR gives users access to a shared database of patient data doesn't make them not "singleware." The shared database must contain for display real-time data about other relevant users, their goals, and task status in order of an EMR to quality as "clinical groupware."
Consider these major dimensions of pediatric EMR usability: naturalness, consistency, relevance, supportiveness, and flexibility. Workflow management concepts provide a useful bridge from usability concepts applied to single users to usability applied to users in teams. Each concept, realized correctly, contributes to shorter cycle time (encounter length), increased throughput (patient volume), and a savings of time and resources that can be applied to seeing more patients, spending more time with each patient, and going home earlier.
The Usability Principle of Natural Workflow
Naturalness is the degree to which an application’s behavior matches task structure. In the case of workflow management, multiple task structures stretch across multiple pediatric EMR users in multiple roles. A patient visit to a pediatric medical practice office involves multiple interactions among patients, nurses, technicians, and pediatricians. Task analysis must therefore span all of these users and roles. Creation of a pediatric process definition is an example of this kind of task analysis, and results in a machine executable (by the workflow engine) representation of task structure.
The Usability Principle of Consistent Workflow
Consistency is the degree to which an application reinforces and relies on user expectations. Process definitions enforce (and therefore reinforce) consistency of pediatric EMR user interactions with each other and with respect to task goals and context. Over time, team members rely on this consistency to achieve highly automated and interleaved behavior (an important effect of well-designed clinical groupware). Consistent repetition leads to increased speed and accuracy.
The Usability Principle of Relevant Workflow
Relevance is the degree to which extraneous input and output, which may confuse a user, is eliminated. Too much information can be as bad as not enough. Here, process definitions rely on pediatric EMR user roles (related sets of activities, responsibilities, and skills) to select appropriate screens, screen contents, and interaction behavior.
The Usability Principle of Supportive Workflow
Supportiveness is the degree to which enough information is provided to a user to accomplish tasks. An EMR can support users by contributing to the shared mental model of system state ("shared situational awareness") that allows users to coordinate their activities with respect to each other (another important result of well-designed clinical groupware). For example, since a pediatric EMR workflow system represents and updates task status and responsibility in real time, this data can drive a display that gives all pediatric EMR users the big picture of who is waiting for what, for how long, and who is responsible.
The Usability Principle of Flexible Workflow
Flexibility is the degree to which an application can accommodate user requirements, competencies, and preferences. Unnatural, inconsistent, irrelevant, and unsupportive behaviors (from the perspective of a specific user, task, and context) need to be flexibly changed to become natural, consistent, relevant, and supportive. Plus, different pediatric EMR users may require different process definitions, or share process definitions that can be parameterized to behave differently in different user task-contexts.
The Ideal Pediatric EMR Workflow System (AKA Pediatric EMR Clinical Groupware)
The ideal pediatric or primary care EMR should make the simple easy and fast, and the complex possible and practical. The majority/minority rule applies. A majority of the time processing is simple, easy, and fast (generating the greatest output for the least input, thereby greatly increasing productivity). In the remaining minority of the time, the productivity increase may be less, but at least there are no show stoppers!