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What Tablets Can Teach Us about EHR Usability


Usability remains a matter of personal preference, so the debate over the best tablet can shed light on how we determine the best EHR system for our own use.

If you have followed my blog posts, you realize that I don't think much of EHR certification as currently implemented. The criteria reflect the best that a national committee can do without excluding the products offered by the committee members. The criteria also use terms that may be understandable in broad terms, but which are never precisely defined and present a bizarre mix of the nit-picky and the nebulous. They are simultaneously over-specified and under-specified.

After griping about computer systems for 30 years, regulators have finally gotten one message - usability is a problem. Their response was predictable: Regulate it. National Coordinator of Health IT Farzad Mostashari recently raised the possibility that the Health IT Policy Committee would recommend usability certification. "If you score 71 [on a usability test], you [would] have permission to market EHRs in this country, and if you score 70, you [would] not." He says he’d be surprised if they do. Many of us were also surprised by “meaningful use,” but not Mostashari. (Next, we will need permission to think!)

Think (if it's still allowed) about the parallels. Married couples do not always get along. Conceptually, that's a usability problem. Someone or something that looked sexy and attractive turns out to have traits that prove to be intolerable. That's why the divorce rate is so high. The traits that will eventually annoy you can only be discovered through experience. It's actually much easier to divorce your spouse than it is to divorce your EHR vendor once you have committed a couple of billions of dollars. The solution (if you are in Washington and concerned about the high divorce rate) is to create usability criteria for people and forbid marriages if the individuals score below 71.

Unfortunately, what you learned from your first spouse or first system may not be much help if you make another attempt. Other people and things have different traits, so experience with one is not particularly applicable to others. Usability remains a matter of personal preference. Each person has a unique notion of what constitutes usability, and even that will be highly context and situation dependent.

The iPad and Android tablets provide another example. Unlike EHRs, people are not slow to adopt tablets. Both iPads and Androids appear to be quite usable if judged by what people say and by the volume of sales.

I've been using iPads for three years. There are a number of things that I don't like about them, but for the most part I find them to be highly usable. I recently acquired a Samsung Galaxy Tab 2.0 running Android. I configured it to match my iPad setup as closely as possible. Despite much searching and tweaking, I find the usability of the Android tablet to be very poor. Things that I can do in one tap on the iPad require multiple taps and screen transitions on Android. The iPad is even better at little things, like typing accurately. Apple's algorithms for determining what key I intended to press are superior to Android's which often gives me a letter adjacent to the one I thought I tapped. I have stopped using the Android tablet. If I had paid full price, and knowing both, I would still stop using it and buy an iPad.

But how would I have known any of this if I had not gained extensive experience with both? Based on the available information, they are both great tablets. If there was a government certification program they both would have scored over 70.

After all, the criteria themselves would have been a composite of those products already deemed to be usable - an approach that is both self-serving and based on circular reasoning. If I had gotten either tablet, and never experienced the other, I would have believed that what I had was as good as it gets. If it had been the Android, I would still be using it three years from now and hating every minute of it.

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