“Over My Dead Body”: Why System Usability Matters

It’s widely rumored that a health IT industry executive was unhappy about suggestions that systems have to be usable in the eyes of employees who use them while caring for us. (Us. The patients. Your mother.)

According to the rumor, the exec said “Over my dead body.” As if s/he ran the agency.

Whether or not the rumor’s true it’s not funny. So when I was asked to represent the patient perspective in a keynote June 3 in Washington (details below), I used that phrase as my title.

Here are my slides, with a few changes to make it work better standalone. (If you’ve seen my talks before, skip through the familiar slides.) The “dead body” part starts at #48.

View more presentations or Upload your own.

I don’t think “over my dead body” is an appropriate business argument when the business is healthcare. Systems in any industry that are hard to use are more likely to lead to human error, and in some industries errors cause deaths. Aviation is one, and healthcare is another.

A big difference is that aviation deaths are spectacular and unexpected so they get investigated, while hospital deaths can be blamed on sickness. That’s no excuse for weasels to resist quality regulations: a death is a death.

(Accidental deaths and harm are hard on staff as well as patients, as we’ve covered here.)

I know vendors want their systems to qualify for Federal stimulus incentives under the Meaningful Use regulations. Those incentives are a powerful carrot (higher payments) and stick (penalties, a few years from now), leaning on physicians and hospitals to buy health IT. The big question being defined in the regs is, how good must a system be to qualify the buyer for those incentives?  Can any piece-of-crap system qualify? (See our January post Cream of the Crap – a term used by a hospital, not me, about the system they chose despite  its being crappy!)

As much as I want health providers to get modern with IT, I assert that it’s just plain wrong to force people to buy crappy, hard to use systems. So I think usability is an issue.

Some people have said “Welllllll, but how do you measure usability?” There are experts who do that in other fields – again I’m amazed that healthcare denies knowledge from other industries. But here’s the method we-all had to live by when I was in consumer software: ask users if the system sucks. I said that in the January post:

Here’s one radical idea:

What if a system could only get certified (and thus get the stimulus money) if the people who use it say it basically works??

(Can a system be meaningful if the users say it doesn’t work?)

Guiding principle: ask the workers who are directly impacted if the system screws up.

Some things about healthcare are rocket science. This one isn’t.


About the conference:

AHRQ (“ark”), the Agency for Healthcare Research and Quality, is a division of HHS that sponsors important contracts and grants. On June 3 I gave a keynote at the annual meeting of their health IT grantees and contractors. I’m thrilled that I was invited to represent the patient point of view. And I chose to use the words of that rumor as my title.  I don’t know if the rumor’s true, but my sentiment is true regardless: this is not just a business parameter to be kicked around like a football. I want the people caring for me in the hospital to be supported by good systems!

I have to say that I was impressed by the brains in the room at that conference. These struck me as competent, thoughtful people – top tier among all the events I’ve attended. AND, for whatever reason, they’ve been thinking too much inside-the-box and inside-the-hospital, and not thinking enough about what I’ve called “the ultimate stakeholder” – the person who dies if the system fails.  This is one of those areas where we can do better, and I think it starts with refusing to accept (or fund) crappy hard-to-use systems.


Posted in: medical records | news & gossip | policy issues | reforming hc | trends & principles




16 Responses to ““Over My Dead Body”: Why System Usability Matters”

  1. "Over My Dead Body": why usability matters (my keynote to #AHRQ contractors & grantees, June 3) http://bit.ly/95MkrW

  2. RT @jourpm: "Over My Dead Body": Why System Usability Matters http://is.gd/cPnl9 (and we wonder why awesome developers shun HIT?!)

  3. […] Article e-Patient Dave, e-patients.net, 14 June 2010 SHARETHIS.addEntry({ title: "“Over My Dead Body”: Why System Usability Matters", url: "http://articles.icmcc.org/2010/06/15/%e2%80%9cover-my-dead-body%e2%80%9d-why-system-usability-matters/" }); […]

  4. SusanCarr says:

    RT @ePatientDave: On e-patients.net: "Over My Dead Body": why usability matters http://bit.ly/95MkrW (from my June 3 #AHRQ keynote)

  5. On e-patients.net: "Over My Dead Body": why usability matters http://bit.ly/95MkrW (from my June 3 #AHRQ keynote)

  6. RT @ePatientDave: On e-patients.net: "Over My Dead Body": why usability matters http://bit.ly/95MkrW (from my June 3 #AHRQ keynote)

  7. A.J. Kandy says:

    RT @ePatientDave: "Over My Dead Body":why usability matters in Electronic Health Records and Health IT http://bit.ly/95MkrW (via @jasphua)

  8. Did my "Over My Dead Body" post stifle thought?? Not a single comment in response! http://bit.ly/95MkrW

  9. Joe McCarthy says:

    Thanks for sharing your story, and your diagnosis and prescription for improving our health system(s) through usability and participation.

    I suspect the lack of [other] comments may be due to the sheer volume of information contained in your fabulous slides, or a case of non-violent (and thus uncommunicated) agreement by people who are reading the post and/or viewing the slides.

    One other possibility, related to usability: I found the automatically advancing “feature” in your embedded SlideBoom presentation to be rather disempowering. I had to pause and click back several times when it went too fast, and often had to manually click forward when it was too slow. I can imagine the potential benefits if an audio narration were aligned with the auto-advancement, but without that, this feature seems more of a bug (in this context).

    • OUCH, Joe! I’m very attuned to the issue you cite (too-fast auto-advance) and I thought I’d shut that off. Apologies – I’ll fix tonight!

      (Yeah, I’m picky about usability, including my own crap. Thanks for speaking up. That prez went through 4 online versions and I guess I muffed that one.)

    • Okay, Joe, I think the auto-advance is fixed. (It was much hairier than I expected, because I use hairy animations and because there’s no way to preview the effect of all the various upload switches.)

      Thanks again for speaking up.

      • Joe McCarthy says:

        Much better – thanks for fixing.

        SlideShare is my usual slide sharing service, but I’ve heard from friends that it does not handle animations well. I hadn’t seen SlideBoom before, but now that I know it can handle animations – for those willing to work at it – I’ll keep that in mind in my future evangelizing of such services.

        • Yeah, Slideboom does animations *and fonts* in ways where Slideshare is the canonical Fail demo.

          There’s an iSpring Free plugin that simplifies uploading from within PPT. Only thing is, I can’t see a way to replace an existing presentation, so using it for corrections seems inexorably to create a new URL.

          My view is that Slideshare is fine for truly feeble PowerPoints (which so many are), or ones that are well done but don’t use animations. Me, I can’t stand putting a slide up there and talking for 5 minutes. But that’s me.

  10. Annie Stith (@Gr8fulAnnie) says:

    Hey, Dave!

    (Patient, here.) It saddens me that you didn’t get more responses to your post. Usability is such a huge part of developing any program, and yet is so often ignored. Developers and programmers can be so focused on the program simply accomplishing its goal (an appropriate perspective) that usability isn’t considered.

    It IS a matter of life and death. Another perspective: A friend of mine had Power of Attorney (POA) when his wife suffered brain damage during the time it took before she was revived from sudden cardiac arrest. He struggled with quality of life and if or how much his wife might recover. The doctors were so unbelievably vague about her current condition (much less hopes of regaining what she’d lost) that it made his struggle SO much harder. Even with a copy of his POA in hand, doctors resisted sharing his wife’s medical file. When he attempted to get information from nurses, he was often misinformed.

    Had there been a healthcare information system in place, my friend could have appropriately been given access to his wife’s files. Maybe then he wouldn’t have had to argue with doctors and be misinformed by nurses. I say “maybe” because without a system that nurses can comprehend and USE, they might very well have input wrong information.

    I’ve battled with seeing my OWN medical files, as well. When I needed to make a decision about having back surgery, the neurosurgeon denied me access to the radiologist’s reports from tests. Thankfully, my primary care physician had been copied on the reports, and he had no hesitation in sharing copies with me. Again, there’s no reason for me to HAVE to do battle with doctors to see my own information. And, for both my friend and I, we were making serious decisions based on that information. If the system is incomprehensible to doctors and other medical staff, patients can’t reasonably rely on the information’s accuracy.

    Just one patient’s perspective.


    • Hi, Annie.

      I’ve decided I’m NOT saddened by having relatively few comments. People I’ve talked to have said they were sobered by it, it really made a dent – they simply didn’t have anything to say.

      Susannah Fox is (imo) our wisest person in this blog’s community, and two years ago she reminded us that what makes a difference isn’t necessarily the traffic count or the noise level: in the game we’re playing (changing healthcare) what makes a much bigger difference is *who* is listening, and whether they’re hearing.

  11. […] Last spring as the Meaningful Use rules were being written, there was talk of mandating that vendors have to make their systems usable for providers in a harried hospital environment. According to rumor, an industry executive said “Over my dead body.” Very funny, making my nurses and doctors use crappy, buggy software. So when I spoke in June at the Agency for Healthcare Research & Quality (AHRQ), I titled my talk “Over My Dead Body: Why Reliable Systems Matter to Patients.” […]

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