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!

Linguistic issues in Healthcare

I'll admit it - I was flattered when Mark Hagland of Healthcare Informatics recently gave me my second interview about CMIO life. During our discussion, he asked me a lot of questions about "What does it mean to be a CMIO?" and "What makes a good CMIO?". And as I was responding, I told him that I feel like a lot of my job is about offering translational services between the clinical side, the administrative side, and the IT side of healthcare.

As a multilingual person who grew up in a multicultural household, I learned a lot about interpreting :

• How culture, context, and language all interplay and influence each other.
• How hard it is to pin down which of the three is more influential in communicating a message.
• How language is sometimes unable to convey a specific message. (* - IMHO, this is why art, poetry, and music exist - To help send those messages where language fails.)

So I feel like a lot of my the CMIO role is like being a United Nations Interpreter - I have to consider the culture, context, and language that each member of a team is using, and try to make sure that the "same message" is being received at the other end of the line.

I can only say that quietly, I see a lot of confusion happening in the national healthcare discussion because we don't appreciate the linguistic issues which contribute to that confusion. We don't see it because we're all speaking English... right?

To give an example of what I'm talking about, I sometimes act as an interpreter between the German and American members of my family. This is a fairly straightforward act, where :

• At dinner, one of my German family members will say something in German.
• I listen to what they said, and have to consider both the context of the message, and the German cultural perspective of what they said
• I have to mentally prepare a translation with a similar theme in English with an American perspective.
• I have to help verify the context and quality of my mental translation by comparing it with a similar American cultural context (if one exists). 
• Sometimes, despite your best efforts, there is no way to do this 100% effectively - This is why there are words that 'cannot really be translated', like "Kindergarten" and "schadenfreude" which make their way into the English/American lexicon.
• I deliver the best English translation I can that, hopefully, is as close to the content, context, and spirit of the original message.

This process of translation is fairly intuitive to most people when speaking different languages because, well, they are different languages - There is virtually no way my American family and German family can talk to each other without an interpreter.

The problem in many healthcare discussions is that we're all speaking English - So the context and cultural perspectives of different members of the healthcare workforce are not as apparent, and so it's not as immediately clear that you've crossed cultural boundaries. In short - It's very easy for messages to get mixed up because people aren't always aware when they have crossed a cultural boundary. People may have experienced this in any business, but healthcare is particularly susceptible to this due to the many cultures that interplay in healthcare - Clinical, administrative, technical, business, etc.

As a CMIO who grew up multilingual, however, I'm keenly watching for those cultural boundaries, and playing so many roles, I try to act as an interpreter and watch to make sure the right message was received on both sides of the fence.

Still, even with my experience, I was recently humbled when I inadvertently crossed a culture boundary  - I tried to let a family member know I moved their mother to the ICU just as a precaution :

Me : "I moved your mother from the floor to the ICU just as a precaution."

Family : "What was my mother doing on the floor? Did she trip and fall?" 

(Same word, different culture and context - Good thing this person asked for clarification! What if the family hadn't asked for clarification?)

An interesting parallel to this discussion - UN interpreters are generally expected to study both of their languages equally well and to live in both cultures, so they understand the cultural context, jargon, slang, and idiomatic expressions in both languages. In the same way, I think that's why it's helpful for me to work both clinically and administratively - It helps me understand the language, jargon, slang, and idiomatic expressions of both cultures.

So Mark, as a multicultural, multinational, and multilingual guy himself, totally understood this issue and wrote this really interesting blog post where he spoke about an experience he had while visiting South Korea, when he participated in a 'translational daisy chain' where a diverse group of visitors were trying to help a French-speaking Belgian woman buy tickets. Using a combination of people, all bilingual but speaking different languages, they established a French <> English <> German <> Korean translation chain, and by each person working on their part of the translation, this French-speaking woman was able to buy tickets from a Korean-speaking vendor.

It's one of the craziest stories I've ever heard, but it beautifully demonstrates both the value of bilingualism and the work it takes to get even a simple message across four languages and four cultures. Anyone who has played the game "Telephone" just using English knows how easy it is to fail to relay a message - Imagine doing it across four languages and cultures!

I suppose this might be one of the reasons I see a lot of CMIOs from diverse backgrounds, where something about their life experience taught them to be comfortable crossing cultural boundaries and 'seeing both sides of the coin'. This seems to be a fairly common trait among the other CMIOs I meet. For me, it's part of the reason why I so enjoy helping to further define and clarify the CMIO role - to help healthcare evolve and adapt.

Remember, this is just academic banter, and your mileage may vary. Always enjoy comments, questions, thoughts, and discussion!