Less is More
–Mies van der Rohe

In high school English class, many of my generation were forced to study a book about writing known as “Strunk and White.” Compared to many other books we were forced to read, it had many advantages. It was short. It was to-the-point. It was full of pithy sayings, the most pithy: omit needless words.

In Cognitive Friction, we extended the idea to graphical computer user interfaces as “omit needless pixels.” In Performance, Data Pixels, Location, and Preattentive Attributes we looked at Nielsen and Tahir’s analysis of the percentage of a home page’s area devoted to different purposes; in this way, we could determine which were valid data pixels, which were not, and the ratio of data to non-data pixels.

In Lessons from Tufte, we read from The Visual Display of Quantitative Information

The larger the share of a graphic’s ink devoted to data, the better (other relevant matters being equal):

Maximize the data-ink ratio, within reason.

Every bit of ink on a graphic requires a reason. And nearly always that reason should be that the ink presents new information. …

The other side of increasing the proportion of data-ink is an erasing principle:

Erase non-data-ink, within reason.

Ink that fails to depict statistical information does not have much interest to the viewer of a graphic; in fact, sometimes such nondata-ink clutters up the data…

In Menu we discussed “analysis paralysis”: the more choices on a computer screen, the harder it is to use, and the more likely a user will make a mistake; and the importance of paring down the number of choices. We may consider the area of a computer screen devoted to choices that users never or rarely use to be made up of non-data-pixels. What is worse, these supernumerary choices distract from the data pixels, and since they are worse than other non-data pixels (they distract more), we may term them anti-data-pixels.

Want to make a computer screen or web page better? First, omit anti-data pixels. In a future post, I will discuss a heuristic (fancy name for a simple rule) for determining how to do this. Next, omit non-data pixels. What is left should be pure, clean, relevant data.

Death to anti-data pixels!

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Dr. Vivek Reddy, a neurologist at the University of Pittsburgh Medical Center, also works on its digital records effort.

In a February 19 article in the New York Times,  Julie Creswell calls the healthcare IT portion of the 2009 stimulus bill (American Recovery and Reinvestment Act of 2009)  ‘a $19 billion government “giveaway”’ resulting from the lobbying of the big HIS vendors. One of the quotes in her article points out the usability limitations of these big HIS systems: ‘“On a really good day, you might be able to call the system mediocre, but most of the time, it’s lousy,” said Michael Callaham, the chairman of the department of emergency medicine at the University of California, San Francisco Medical Center.’

Skeuomorphism has been around for a long time.

Architects including Frank Lloyd Wright have eschewed it. Alan Cooper, known as one of the founding fathers of user interaction design for computer systems, decried it in the first edition of his classic text, About Face: Essentials of User Interaction Design. And more recently (~October 2012), people have compared Apple products with the new anti-skeuomorphic Modern UI (in-speak for User Interface) of Windows 8, previously known as Metro, and accused Apple of poor design because of rampant excess skeuomorphism.

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Skeuomorphism in architecture (or car decoration) might be wood-grained vinyl. Skeuomorphism in software design might be a graphic of a spiral binding along the edge of a note-taking program’s screen.

Is it good? Is it bad?

Figure from Mullet+Sano: Designing Visual Interfaces

There are arguments in favor of skeuomorphism… it makes it easier for new users to figure out what software does. A good example is the shutter sound on cellphone cameras. There is a need for a sound that tells you that a picture has been taken. And using a sound that associates with old shutter cameras works. Even if you’ve never used a camera with an actual shutter, you may be familiar with the sound, as it’s a defacto standard for all sorts of digital still cameras. Donald Norman and Jakob Nielsen point out that if we flout standards – such as underlined blue text for links, or skeuomorphic Trompe-l’œil buttons to push with our mouse  – we do so at peril of making something unusable, something poorly learnable and poorly memorable.

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But, in a January 2013 article in Forbes magazine “Will Apple Dump Skeuomorphics In iOS?” Tim Worstall writes: this is only important in the transition from one way of doing things to a new one. You’ve only got to appeal to memories and habits of older technologies when people still have those memories and habits. Once you’ve a new generation of people, people who have grown up only ever having used the new technology, you simply don’t need those reminders of the old.

I’m not sure skeuomorphism is the best way to transition to a new paradigm. If the new paradigm has an excellent user interaction design, there is little or no need for skeuomorphism. It’s a crutch, and not a great one at that.

David Pogue writes, in the Scientific American article “Apple Shouldn’t Make Software Look Like Real Objects“: How many members of Generation Y have ever even used a Rolodex?

He points out how Windows 8 has gone the exact opposite direction: no skeuomorphs to be seen. Big, boxy tiles, which you can touch with a finger (well, unless you have a PC with a non-touch screen). No shading. No shadows. No raised buttons to provide affordance.

I have my own issues with Windows 8. Trashing the Start Button to force people  to the “Modern-previously-known-as-Metro” start screen is a blatant ploy to make people learn the new Modern interface.

Not that learning the new interface is bad, but having to switch from the desktop to the Modern/Metro interface sucks compared with the Start button as a way to quickly access programs from the desktop. As soon as I got a new PC with Win8, I bought Start8 from Stardock and installed it. Once I made that change, I found Win8 a just outstanding desktop operating system. There are many improvements from Win7. One of my favorites: I can mount .iso CD or DVD images just by double-clicking on them. This means I can make a .iso of a program’s CD for programs it will only install when it knows it’s running from a CD… and just run it from the .iso file. Slick. There are many other improvements under the hood.

But I like the Modern/Metro interface. Skeuomorphism may improve learnability the first time you use a program or device, but it gets in the way after that. Massive simplicity as in the Win8 Modern/Metro interface may take a few seconds more to learn, but it’s still quite easily learnable. And it’s easier to use than the iPad once you learn it.

Metaphor Run Amuck

Skeuomorphism is related to metaphor.

Something on a computer or cellphone screen that looks like a bookshelf is a metaphor. In Cooper’s original 1995 first edition of About Face, he gives a great example of metaphor run amuck, a product which will here remain nameless to avoid embarrassing the original coders. It’s shown to the right. As he says: Never bend your interface to fit a metaphor.

He points out that there is a difference between metaphor (and, by extension, skeuomorphism) and idiom. For example, the standard radiation symbol is an idiom. There is nothing skeuomorphic here: this is an abstract symbol. But it’s very rapidly learnable and memorable. j

Cooper says: All idioms must be learned. Good idioms only need to be learned once.

Windows 8 Modern/Metro interface has good idioms. (It also has good direct manipulation (pressing and sliding tiles, for example. Again quoting Cooper’s About Face: A rich visual interaction is the key to successful direct manipulation. But direct manipulation is a story for another time.)

But my favorite About Face quote is apropos: No matter how cool your interface is, less of it would be better.

Medical software needs less skeuomorphism, such as Cerner FirsNet’s indecipherable icons (for example, the one that is supposed to look like a registration clerk and everyone refers to as “The Buddha”), and more good idioms.

Less is More
–Mies van der Rohe

One of the supposed means to the great gains of electronic health records is that of the Personal Health Record (PHR). Big guns like Microsoft and Google dived into the PHR pool a few years ago (Microsoft HealthVault and Google Health), only to find that the water was quite shallow. Getting information into a Personal Health Record turns out to be so hard, that the effort wasn’t worth the results. Google gave up, at least for now, yet Microsoft persists. (There may be a lesson in there somewhere… ) But, as pointed out in an article on Slashdot, the Department of Health and Human Services has released newly revised rules for the Health Information Privacy and Accountability Act (HIPAA). These are effective on March 26, 2013. This is designed to, among other things, make PHRs more functional. As the press release says: “Patients can ask for a copy of their electronic medical record in an electronic form.”

The Office of Civil Rights (OCR) has an online document THE HIPAA PRIVACY RULE’S RIGHT OF ACCESS AND HEALTH INFORMATION TECHNOLOGY that discusses this in some detail (I guess the OCR has to speak in ALL CAPS). It points out that people may request their medical records by email or a web portal and this has to be accepted the same as a written, signed request. It also says

Electronic access may provide individuals with more timely access to more information in a more convenient manner. For example:

• Electronic copies of PHI may be downloaded to USB thumb-drives or copied to compact discs relatively quickly and may provide individuals with a more convenient means of transporting and maintaining the information.
• EHRs may enable covered entities to offer individuals an immediate and ongoing view into the covered entity’s designated record set(s), either through a personal health record (PHR) or otherwise, while limiting the time, expense, and labor that may be required otherwise in order to provide access to the individual.

The comments in the Federal Register say:

to the extent possible, we expect covered entities to provide the individual with a machine readable copy of the individual’s protected health information. The Department considers machine readable data to mean digital information stored in a standard format enabling the information to be processed and analyzed by computer. For example, this would include providing the individual with an electronic copy of the protected health information in the format of MS Word or Excel, text, HTML, or textbased PDF, among other formats.

This looks like an open invitation for healthcare organizations to get their acts together and support some from of a Personal Health Record, to save money on copying medical records, if nothing else.

Leslie S. Liu, Patrick C. Shih, Gillian R. Hayes of the Department of Informatics at UC Irvine published a paper online a year ago entitled Barriers to the Adoption and Use of Personal Health Record Systems. They point out the potential benefits of a PHR, but ask why only seven million Americans use one.  Yes, interoperability problems make it hard to import electronic records into a PHR, but they also analyze other barriers to wider acceptance of PHRs.

They used discount usability testing, which is described in two major books on the subject that they cite, but also on Jakob Nielsen’s website useit.com.

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Unsurprisingly, given the abysmal state of usability in medical applications in general, usability of these products was poor, which the study implicates as a major factor preventing the adoption of the PHR. The paper even uses the abbreviation “HE” for Heuristic Evaluation, which simply means that when you do usability testing, you follow some rules (duh). My advice is to use well-known heuristics, and a great example of how to do this is in Nielsen and Tahir’s book Homepage Usability: 50 Websites Deconstructed … but keeping your eye out for problems that don’t fit into your heuristic. Remember, usability heuristics have not been around for a long time, so it’s entirely possible you can find a new problem and get a heuristic named after you.

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It’s too bad that I have to keep blogging about how poor usability of medical software is making healthcare more expensive and less efficient. I look forward to, someday, posting a gushing review of how good a particular piece of medical software is. But then, I’ve been looking forward to that for a long, long time.

In the January 2013 HealthAffairs, Arthur L. Kellermann and Spencer S. Jones of the RAND Corporation look back  at the projections of a 2005 RAND study of healthcare IT. Why, in defiance of that study’s projections, are our medical computer systems not saving us $81 billion a year? They list reasons: slow adoption, lack of interoperability, and – you guessed it – poor usability. So, just maybe, if you get vendor CEOs and hospital CIOs to spend a few hours browsing the essays on this website, you can save the country billions of dollars. (Not to mention saving hospitals’ money and making more money for vendors.) Who’d have figured?

The Cost Disease is both the name of a book, and the economic theory espoused by this book.

The theory is relatively simple at its base. There are two segments to our modern economy, the progressive and the stagnant.

The progressive sector makes rapid improvement in efficiency. Examples include manufacture, particularly of items such as computers and cellphones.

The stagnant sector, including healthcare, education and live entertainment, due to dependence on human-human interaction, does not improve its efficiency rapidly.

Thus, the fraction of our GNP (and your paycheck) spent on the stagnant sector will increase. Continously.

Note that I said the fraction.

This may seem depressing. But the authors point out that, in real terms, our society, globally, is becoming richer. Therefore, despite the increasing fraction we will spend on the stagnant sector, we will be able to afford it. We will be able to afford more and better healthcare, education, and live entertainment.

Nonetheless, we need to do what we can to make the stagnant sectors more progressive. They give examples in the book of how healthcare, in particular, can become more progressive.

It is apparent that there will be an excellent ROI in healthcare by maximizing the efficiency of our healthcare personnel. Some big projects like RHIOs will contribute to this, but at a massive cost. But think – how much of our healthcare personnel’s time is spent using – or cursing at – computers?  Given the sad state of usability of our medical software, we will get a lot better ROI by simply making simple changes to our software to make it more usable. The cost of these changes is small compared to a RHIO, but the incremental benefit is huge. Thus, this website.

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An article in the New York Times points up some of the shortcomings of the push for meaningful use of electronic medical records (EMR): it’s vulnerable to fraud. The Department of Health and Human Services is shocked, just shocked, that perhaps some physicians and hospitals may have not been entirely accurate in self-reporting how well they’ve converted to an EMR, just to get a few million dollars.

But the part of the article that got my attention was this quote from Lynne Thomas Gordon, the chief executive of the American Health Information Management Association, a trade group in Chicago:

We’ve gone from the horse and buggy to the Model T, and we don’t know the rules of the road. Now we’ve had a big car pileup.

The reason I love this aphorism is not because I am shocked at the poor HHS oversight of the meaningful use process. To that, I say “duh.”

But it encapsulates where I think we are in terms of usability of medical software. Even our best software and hardware – iPhones and Android phones, Google search, Google Maps, and the like – are still barely beyond the Model T phase. Our medical software, far behind these market leaders, doesn’t even make it to the Model T level. Maybe its to the “pileup of Model Ts” phase.

We don’t need Model Ts, we need something like the new Tesla electric car.

Faced with a long dinner menu, it’s hard to decide what to order. (Even with a medium-sized menu, my wife always says “You go ahead and order, I haven’t decided yet.” But that’s extreme.)

It’s not just an urban legend. There are scientific studies that demonstrate it.

The study When Choice is Demotivating by Sheena Ivengar of Columbia University showed this:

In a grocery store, set up a jam-tasting station.

First, put out four different jams, and let people taste, and if they wish, buy.

Four out of ten people who stop by will taste some jam. Of those people who stopped to taste, three out of ten will buy some jam.

Next, put out twenty-four jams.

Six out of ten people will stop to taste. But of those who taste, less than one in ten (3%) will buy.

Why?

Cognitive friction.

The more menu choices, the harder it is to decide.

This problem has been known for millennia. Aesop relates the traditional tale of the fox and the cat. The idea is ensconced in the pop psychology literature as analysis paralysis. You can even buy a book about it.

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In Cerner FirstNet, I am confronted with a similar plethora of choices. For instance, to get to most of the information in Cerner from FirstNet, I need to click on a menu item called Chart. (There are other ways to get to this information, but this seems the simplest.)

However, the menu I am confronted with is as follows:

ED Summary
Allergies
Orders
Med Grid
EMAR
MAR Sum
Med Review
Flowsheet
Med Profile
VS
IView/IQ
Lab
Micro
Reports
Rad
PowerNote 2G
Impression and Plan
Clin Notes
Caredex
Assess
Nurse Notes
Form Text
Forms
Problems and Diagnoses
Pt. Info
Immunizations
Communication View
36hr
Newborn view
Newborn Genview (new)
Labor _Delivery view
Health Maintenance
Clinical Calculator
Ad Hoc Charting
Depart Process
Tear Off This View
Attach to Chart
Chart Accessed by >
Close Charts

That’s thirty-nine choices. I have highlighted the only options on this menu that I use. I have no idea what most of the rest are. Nor do I need to know what they are to do my job. (P.S.: that ED Summary? I don’t find it useful. Sorry.)

Oh, how much simpler it would be to find my needles if they weren’t in such a big haystack. And I would less-often click on the wrong menu item, if there were fewer items, and they were bigger.

Why can’t I have a shorter menu? All the things I don’t use could be grouped under a single “Rarely-Used” menu item!

Wait, the developer says. People keep asking for all these menu items so we keep adding them.

But I’m not “people” or even “users.” I am an emergency physician. And in my role, I - and all the other people|users - need menus that are customized for our specific roles.

Yes, it takes more work. You have to figure out which menu items I - and my 80 partners - use, and which we don’t. So? We’re worth it. And it makes a much, much better product.

I hope someone at Cerner reads this.