Usability is an “ility” too.

The recent news from CMS is that the “Meaningful Use” program, which was part of a large government effort to promote the use of Electric Health Record (EHR) systems, is being renamed to the “Promoting Interoperability” program.

They say that “To continue their commitment to promoting and prioritizing interoperability of health care data, the Centers for Medicare & Medicaid Services (CMS) is overhauling and streamlining the Electronic Health Record (EHR) Incentive Programs for hospitals as well as for the Advancing Care Information performance category of the Merit-based Incentive Payment System (MIPS), which is one track of the Quality Payment Program.”

We are all for streamlining the EHR incentive programs, and for more clarity on the future of both the MIPS and MACRA programs. But by naming this program “Promoting Interoperability” it seems as if they are turning their back on a large problem with EHRs that is causing actual patient harm—namely Usability.

The lack of usability of electronic health records (EHRs) and healthcare IT applications, in general, has been in the news again. A research report published in the Journal of the American Medical Association (JAMA) analyzed voluntary error reports associated with EHR systems and found that problems with EHR usability may have directly resulted in patient harm (Howe JL ; Adams KT ; Hettinger AZ; et al. Electronic health record usability issues and potential contribution to patient harm. JAMA. 2018; 319: 1276-1278).

We’ve heard time and time again that developers need to focus on “Stability,” “Reliability,” “Scalability” and “Interoperability” of systems. We’ve sometimes heard a need to focus on “Accessibility”, but usually they are NOT referring to designing a system that is usable for those of us with different abilities but getting more people the ability to use a system. These are all important “ilities” but without a focus on “Usability” none of the others matter.

Stability and reliability of a system are important. A system that crashes and that doesn’t provide its service 24/7/365 does little to promote or solve a business problem. But if the end users can not figure out how to perform their task on a stable or reliable system, it doesn’t matter that it is crashing or not.

Scalability is very important as a system becomes more and more successful and needs to be able to handle the stresses of additional users doing more and more work. It is a problem that every business hope that they have to solve. But if the end users can’t figure out how to do their work, they will not recommend that system to their peers, and they might not come back. Without satisfied users, scalability isn’t important.

Interoperability is an important feature across the internet. We like to joke that “the best thing about standards is that there are so many to choose from.” That being said, it is important for an enterprise-class system to support multiple standards and be able to communicate across multiple platforms. In healthcare, the fax machine has been the “least common denominator” standard that for many is the only way to communicate health information between providers. The fax machine has gone the way of the Dodo bird ("Raphus cucullatus") in most all other industries, except healthcare.

However, while supporting multiple standards, and communication protocols across various systems (using a secure API and FHIR, for example) is great, if the end users are unable to navigate the workflow associated with the sharing of patient data due to a poor user experience, it doesn’t really matter which APIs or which communication protocol is supported the interoperability will default to a Fax machine.

The best thing about standards is that there are so many to choose from!

Accessibility is more important than most realize. We often advocate for the principles of “Universal Design” as a way of exceeding the requirements of Section 508 of the ADA. The intent of universal design is to simplify life for everyone by making products, communications, and the built environment more usable by as many people as possible at little or no extra cost. Universal design benefits people of all ages and abilities. Think “Curb Cuts.”

Usability is an “ility” too.

Developers are not thinking about the usability issues that they will likely have to deal with "down the road" when they produce software systems using an Engineering-centric Design paradigm. “The money spent on marketing bad designs, building bad designs, supporting bad designs dwarfs the money people are willing to spend to ensure that the design of their products support user needs, and are effective, efficient and satisfying to use. (Dominira Saul of” and without usability, the others just don’t matter.

Given that the lack of usability in EHRs is a patient safety issue, and the ONC/CMS has created the "Safety-enhanced Design" euphemism for usability as part of the 2014/2015 certification, perhaps they should have renamed the meaningful use program to "Promoting Interoperability and Safety-enhanced Design." Anything that includes usability (aka Safety-enhanced Design) would be better than focusing only on Interoperability.

We will add that to the public comments on the CMS/ONC website.

The Usability People work with you on improving the Usability of Healthcare IT.

For expert 2015 ONC Safety-enhanced Design (aka Usability) evaluation of your EHR: contact The Usability People

The Usability People

Together we may save a life! #SafeHealthIT