Culture, Terminology, and EMR Usability

Hi fellow Informatics friends and colleagues,

When sharing the secrets of electronic medical record (EMR) usability, some people are surprised at how much culture and terminology impacts user satisfaction. Allow me to explain.

EMRs are essentially tools used to store and retrieve patient care information. When configuring an EMR, the most common mistake is thinking it's 'like paper', simply a bunch of words, lines, and boxes on a page. EMRs are different - Buttons open menus that lead to other tools and actions, so it's more helpful to think of it more like you are organizing a closet: 

• Socks go in the sock drawer.
• T-shirts go in the t-shirt drawer.
• ... and so on.

Only an electronic patient record literally contains hundreds of drawers, each containing as few as a handful, or as many as hundreds of documents, images, vitals, or other data elements. E.g. : 

... and when you click on the button "RADIOLOGY ORDERS", one would expect to find the orders related to diagnostic and therapeutic/procedural radiology modalities.

So a key design element to consider : 

• How many items do you need to store in a chart, for patient care purposes?
• In which 'drawers' will you store them?

And so when organizing a closet at home, most people realize they don't have room for a separate drawer for every piece of clothing, so they will use some categorization scheme (that makes sense to them) to combine related items in the same drawer, E.g. : 

• Top Drawer = Undergarments (Socks, Underwear, and T-shirts)
• Bottom Drawer = Outer garments (Shirts / Pants)

We don't consciously think about categorization schemes very much, but our brains do this naturally, to try to make sense of the world, and establish a pattern that will ultimately help us get dressed in the morning. 

Anyone who's ever had to share a closet, however, knows there can be disagreements about categorization schemes, resulting in some interesting household debates. If you have children, you also know it's helpful to label drawers, or explain the categorization scheme, so your kids can find their clothes in the right drawers. Food pantries and refrigerators are common sources of domestic debates, because different family members might have different ideas about ideal organizational schemes.

So it's no surprise that people who are responsible for configuring and organizing an EMR often stumble upon the many cultural differences in thinking and terminology between "healthcare tribes" - E.g. between physicians, nurses, pharmacists, radiologists, laboratorians, ancillary services, medical records, finance, etc.

Here's a good teaching example to better understand what I'm talking about, and how these terminology issues have real-world impact in user EMR satisfaction : 

Imagine it's the year 2050. 

You run a hospital with an EMR. It is suddenly discovered that tomatoes save lives, so you prepare to have tomatoes in your hospital, keeping them in your Pyxis machine, and create tomato orders in your EMR, to order and release the tomatoes for patient care (when needed). 

After meeting with your available subject matter experts (SMEs), many of whom, for scheduling reasons, just happen to be from clinical Tribe A - your analysts build the "Tomato" order, and make it available under the "Vegetable" menu choice below :

Shortly after building this, you suddenly get complaints from Tribe B users, who couldn't show up to the earlier meeting but say, "Hey wait, tomatoes are technically berries, which are technically fruit - Here is the evidence : https://en.wikipedia.org/wiki/Tomato - So they should be listed under the "Fruit" menu choice instead! Those of us who know this can never find the Tomato order!"

You also get complaints from Tribe C users, who say, "What's a Tomato? We've never heard of that. Oh, wait, you mean that red thing we put in our salads/sauces/sandwiches? We've been doing this for 20 years, and in our experience, we've always called it a Golden Cherry."

Do you :

• OPTION 1. Listen to Tribe A, and file the tomato order under the "vegetable" menu, and educate Tribes B and C that tomatoes are red fruit that grow on a vine, are commonly used to make sauces/salads/sandwich toppings, and most commonly thought of as vegetables?

• OPTION 2. Listen to Tribe B, file the tomato order under the "fruit" menu, and educate Tribes A and C that tomatoes are red fruit that grow on a vine, are commonly used to make sauces/salads/sandwich toppings, and correctly categorized as fruit? 

• OPTION 3. Listen to Tribes A and C, rename the tomato order to a golden cherry order, file it under "vegetable", and educate Tribe A that tomatoes will now be referred to as a golden cherry and will be filed under the vegetable menu? 

• OPTION 4. Listen to Tribes B and C, rename the tomato order to a golden cherry order, file it under "fruit", and educate Tribe B that tomatoes will now be referred to as a golden cherry, and will be filed under the fruit menu? 

• OPTION 5. Bring Tribes A, B, and C together for a meeting, review the concepts, terminology, and taxonomy of tomatoes together, and agree to a functional definition (for your glossary!) that meets the needs of all three tribes : 

Tomato ('golden cherry') - A common red fruit/vegetable that grows on a vine in temperate climates, that is commonly used to make salads, sauces, and sandwich toppings. 

... and then build the tomato order, attach a synonym of 'golden cherry', and then file it under :

• the "vegetable" menu choice? 

• the "fruit" menu choice? 

• BOTH the "vegetable" and "fruit" menus? (making Tribe A complain that it shouldn't be making the fruit menu look messy, and Tribe B complain it shouldn't be making the vegetable menu look messy) 

• Or build a hybrid "vegetable/fruit" menu choice? 

... or more options we haven't considered yet?

How these terminology, taxonomy, and conceptual issue get managed will ultimately impact the satisfaction of users who are trying to find a tomato ('golden cherry') in the EMR for patient care.

Hope you enjoyed chewing on this interesting EMR terminology challenge! If you think terminology issues might be impacting your workflow, feel free to ask your local clinical informaticist for help! (#whyinformatics!)

Remember this blog is for education and sharing purposes only. Have other examples of terminology and classification systems impacting EMR usability and satisfaction? Or have you struggled with this yourself? Feel free to share in the comments section below!