Usability in Healthcare: A ‘Wicked’ Problem

The use of information and communications technologies (ICT) in healthcare has been heralded as a potential solution to issues of high cost, poor quality, and unsatisfactory patient care experience. However, the use of ICT to deliver safe and sustainable healthcare systems has been described as a “wicked problem,” referring to the complex web of stakeholders, systems, and legislative parameters involved. Because of its complexity, inherent unpredictability, and often erratic nature, the use of ICT in the healthcare system requires unique attention to context.

In the U.S., the 2009 Health Information Technology for Economic and Clinical Health Act (HITECH Act) established the Office of the National Coordinator for Health Information Technology (ONC). It also introduced the terms “meaningful use” of “certified EHR technology” and offered incentive payments to eligible professionals and hospitals. The Meaningful Use program is built on the concept that certified electronic health record (EHR) use may improve quality, safety, efficiency, and reduce health disparities. Related goals include actively engaging patients and their families in quality care, improving care coordination, and informing population and public health.

The basic idea is that collectively these practices would lead to better clinical outcomes, improved population health outcomes, increased transparency and efficiency, empowered individuals, more robust research data on health systems, and would help maintain privacy and security of patient health information.

The result has been rapidly increased use of EHRs. The US Department of Health and Human Services estimates that use of an EHR by office-based physician practices was up to 78% in 2013 (from 18% in 2001) and 89% of critical access hospitals were using EHRs by the end of 2013.

Despite widespread use however, most of us have had bad experiences with the usability of EHRs. EHR usability is a significant weakness in healthcare, stifling efforts to demonstrate improvements in efficacy or quality of care. While this may stem from a lack of focus on usability in the process of ramping up EHR use, it is also caused by poor translation of existing and well known best practices to ensure usability from the field of design in healthcare. In many cases, the user interface for EHRs might best be described as a harkening back to the days of MS-DOS. There is substantial room for improvement in the design of EHR systems. Unfortunately, because EHRs often require complex technical integration, design and usability are often an afterthought and fail to incorporate a robust user-centered design process (see Figure 1) or full scale usability testing.

Process diagram

The user-centered design process should follow three key steps: identify the needs of stakeholders and their requirements, analyze those needs by prioritizing according to a model like SMART (elements must meet the following criteria: be specific, measurable, attainable, realizable, and traceable), then implement the design by testing, launching, and evaluating it in an iterative manner. Read the text in this image.

The Stakeholder Environment

The stakeholders in the healthcare UX environment are a diverse group, including both a wide range of people and an equally diverse world of devices and systems, all of whom interact with the EHR in some way. When rule number one is to “know your audience,” what do you do when your audience is this diverse in terms of both the range of stakeholder types and the tasks performed? Perhaps the best recommendation is to think about them in groups.


The use of new technologies like netbooks, tablets, mini-tablets, smartphones, and connected eyewear in the clinical encounter has only increased the likelihood that your primary care doctor is a key actor in selecting and maintaining your EHR. Still, much of the work involved in creating and maintaining EHRs falls to other members of your clinical team. For a designer, this means that understanding not just the different clinical roles, but also the workflow and the (often hierarchical) work system are important elements of usability.

Vendors and systems engineers

You might not think of the people who design EHRs as stakeholders, but when so many systems must work together, the environment in which products are developed must be considered. There are two groups of EHRs, developed in different ways:

  • One group of products was developed at the grass roots by hospital or medical organizations with vision and technical capabilities aiming to meet their own needs.
  • The other started as a niche market for technology companies with experience into existing systems in medicine.

Today, in the name of interoperability, grass roots EHRs are being replaced by systems from large companies like Cerner, Epic, Allscripts, and GE. These new products are helping define the emerging UI/UX of EHR systems. With both development experience and technological capacity, these companies work across disparate systems—from radiology images and laboratory results to claims and billing—and they offer a unique perspective on design and implementation, at least for specific use cases.

Unfortunately, because EHRs often require complex technical integration, design and usability are often an afterthought and fail to incorporate a robust user-centered design process or full scale usability testing.


At some time we are all likely to be patients. The information needed for diagnosis and treatment should be patient-centered. It should be available to us wherever we are (interoperable), and it should result in safe and effective treatment. And, this information should be maintained in a secure and private manner, giving individual patients control of how this information is shared.

Integration of systems and devices

EHRs require data across a group of integrated, previously stand-alone, systems. Examples include products to manage laboratory results, claims information, medications, medical history, and a wide variety of other clinical systems and encounter information. Creating even a loose digital connection between these different sources can be difficult and use can be limited. Together, a variety of efforts to create guidelines and standards for EHR documentation (for example, Systematized Nomenclature of Medicine – Clinical Terms and Clinical Document Architecture), information transport (for example, Health Level 7 messaging, the Direct Project), and security while maintaining patient confidentiality according to the Health Insurance Portability and Accountability Act (HIPAA), substantially improves the overall functionality of EHRs.

Agency or government

Public health agencies also use information systems that are not necessarily well integrated either within the agency, between agencies, or between the agency and the rest of the healthcare system. Examples include information on disease surveillance and epidemiology, immunizations, and environmental health. Using data contained in an EHR to facilitate these public health activities can be a substantial benefit in improving the health of an overall population.

The Case for Guidelines

User-centered design, where the user is centrally involved in all stages of the design process, is critical to improving the design of EHRs. Finding common guidelines is not simple when the user environment is diverse and the tasks performed within the system range from simple to highly specialized.

One organization, the National Center for Cognitive Informatics & Decision Making in Healthcare (NCCD), is working on an HTML5 based publication the “Inspired EHRs: Designing for Clinicians iBook.” The aim is to provide more detailed guidance on issues of design for EHRs and the clinical environment. The current working prototype of the iBook focuses on the essential human factors that affect perception, like seeking familiar patterns or our tendency to seek out whole shapes rather than individual parts. It also includes design principles covering topics from the development of a mental model to addressing complexity and the use of color.

Established techniques and guidelines can provide both broad overarching principles and help facilitate local, detailed elements of a given implementation.

Overarching Guidelines

Some guidelines, like those outlined by the NCCD apply broadly to all implementations of an EHR. They are intended to help guide the designer on the fundamental tenets of design which help ensure proper usability.

A table of 9 Usability Elements: Simplicity, Naturalness, Consistency, Forgiveness and Feedback, Effective Use of Language, Efficient Interactions, Effective Information Presentation, Preservation of Context, and Minimize Cognitive Load.

The healthcare IT organization HIMSS ( is working on the challenges of EHR usability. Their elements of usability include considerations for the healthcare context. (Courtesy HIMSS,


In virtually all EHR implementations there are design implications to the localization of the system that can significantly impact usability. These are often the result of ad hoc configurations or accommodations focused on the integration of existing systems and any limitations that this process might surface. They also tend to facilitate existing best practices for a given healthcare system and the successful workflows that support those practices, even when not universal for a given EHR. More often than not, this means that EHR implementation, regardless of the relative robustness of a vendor system, is highly customized for a given environment or context. To be successful, UX designers need to bring both an understanding of good practice as well as a willingness to apply design guidelines to specific problems encountered in implementation.

Implications for a UX Designer

Just as a designer considers the difference between a first time user and a repeat user, designers who are new to the healthcare domain need to consider how this context represents some unique challenges.

  • Today’s EHR implementations still have problems with system integration that can make it hard to design seamless workflows with good usability.
  • There are many uses of the data the EHR maintains besides its primary function of displaying a patient record. Often called clinical data warehouses, these systems, often database driven, support a wide variety of research and surveillance activities aimed at improving quality and require their own interface guidelines.
  • Usability methods need to consider the entire socio-technical system, not just the individual user.

In healthcare systems design, the aphorism says: “If content is King, context is God.” In this environment, the users are diverse, they interact with the system at a variety of different levels performing a range of work tasks from simple to complex, and they are almost always making tradeoffs based on time or resource limitations. But, today’s focus on meaningful use of electronic health records represents an unprecedented opportunity to refine the design process in this domain and bring a fundamental understanding of the impact of usability back into the design and development of EHRs.

If you are interested in working in healthcare design, it’s the perfect time. Vendors and hospital systems are both seeking out designers with relevant usability expertise. Go get involved!

Text in Figure 1: User Centered Design Process

The diagram shows three concentric rings of elements of a UCD process.

The inner ring has three main areas of work

  • Identify
  • Analyze (SMART-approach)
  • Implement

The middle ring elaborates

  • Engage Stakeholders
  • Solicit Feedback
  • Identify Requirements
  • Apply SMART
  • Gather Feedback
  • Prioritize
  • Test
  • Launch
  • Evaluate

The outer ring has values and benefits

  • Increase exposure
  • Active communication
  • Improve credibility
  • Foster Trust
  • Reduce Resource Burden
  • Integrate Public Heath and IT
  • Increase utilization
  • Improve performance
  • Transparency

Marcial, L. (2014). Usability in Healthcare: A ‘Wicked’ Problem. User Experience Magazine, 14(3).
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