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Dan Bricklin: Still Productive After All These Years

If you ever used Excel or Google’s spreadsheet, you owe Dan Bricklin a thanks. In 1978, Bricklin had the idea to automate table creation. Along with fellow programmer Dan Fylstra, Bricklin worked out the program’s layout, commands and internal routines on a 40 column Apple II. They called it VisiCalc and it spawned the first real business interest in microcomputers. Here’s what that first screen looked like.


The appeal to business was simple. Put in a what if number and you instantly saw the result. Moreover, until then if you made a table you had to spend much time doing footings, that is, making sure that the vertical and horizontal totals agreed. VisiCalc did that for you, eliminating time and errors.

Bricklin, unlike many of the other PC pioneers did not go on to build a large company, etc. Instead, he has founded small businesses focused on innovations in user design and applications. Most remarkable, he’s never lost his touch for user views and usability.

So, what’s this got to do with EHRs? Much. Below is Bricklin’s take on designing apps and sites that use different platforms and OS. In it he moves quickly from automating spreadsheets to today’s challenges, including what to do with left-handed users on tablets.


When Things Go Wrong, The Caterer Gets The Blame

This note was published as a guest article on Shahid Shah’s blog.

From Shahid: Carl Bergman, a seasoned systems analyst and project manager, is Managing Partner of and has been sharing a number of ideas for improving EHR usability with me via email. Since I loved his enthusiasm and agreed with his ideas, I invited Carl to share with us some more detail around how to improve the EHR user experience. Here’s what Carl had to say:

Earlier this year, we went to an outdoor wedding. It was wonderful. The weather, the bride, the ceremony and the food that followed were all great. Curious, I asked the caterer how she did it. Here’s what she told me:

“We do dozens of these a year, most go really well, like this one. Some not so well. When that happens, I’ve learned one thing. Whenever things go wrong, no matter who’s at fault, I get the blame. It doesn’t matter if the florist screwed up the flowers, the venue failed to turn on the PA or the rental company delivered the wrong chairs, I get blamed.

‘“So a long time ago, I decided that if I was going to get blamed, I’d just assume that I’m in charge of everything. I tell my clients, not to worry. I’m their coordinator and will move things along, so they don’t need to worry. They love it and it’s in my interest.”

It’s a good lesson for anyone serving cake or building a system. Complaints about EHRs’ user interfaces are rife, but few detractors bother to differentiate among the product, implementation, support or user problems. Regardless, the developer gets the blame, even if you did nothing wrong, so you just as well turn it to your advantage.

There are several things, some counterintuitive, that you can do to head off problems, improve user satisfaction and avoid complaints. As with the caterer, the first thing is to assume you are in charge of making things go well. More specifically, taking steps such as these:

Developing for Usability

  • Define the Problem. Vendors and their developers may believe they know their product’s I/Fs, but when pressed many have only anecdotal knowledge. Fortunately, there are objective ways to document how your EHR performs. As I’ve noted in other posts, the University of Texas Health Science Center, National Center for Cognitive Informatics and Decision Making (NCCD) free tool, TURF, is a versatile app for documenting and analyzing EHR performance. It shows how users work with EHRs. It also lets you compare that behavior to the National Institute of Standards and Technology’s EHR usability protocol 7804.
  • Sunk Cost and Cash Cows. Vendors whose products are selling well are loath to mess with success. It’s not easy to recognize that what works today may fall behind. However, vendors need to recognize that usability shortcomings will take a toll and endanger both their investment and returns.
  • Aware Development. It’s no secret that development teams are often closed shops. Adding UI/UX specialists, if not already on the team, is an important step. Equally important is keeping the team focused outward. Given that many EHRs are the child of one clinician’s vision, it is often difficult to insure that the team sees beyond the initial vision to include others’ ideas.

Let the Message Through

  • Agreements. Your company lawyer did a great job of protecting you from being sued. Are you so protected, though, that your client can’t talk about problems? Client complaints may be on target or way off, but if they are afraid to tell you or discuss it with anyone, how will you know?
  • User Groups. If you don’t have a formal way for your users to discuss problems and solutions, start one. Even if you have one, if users have started their own, does it cover topics you’ve avoided?
  • Support. Years ago, WordPerfect required each of their execs to spend a day manning their help line. Today, there are many ways to communicate with users, but spending time fielding support issues can give you a feel for your users’ concerns. It can also tell you not only how your support system is doing, but also if it’s passing important issues up the line.

Implementing for Success

  • Participation. Implementing an EHR within an existing environment often builds in problems you can’t control, but have to work with. Even if the client acknowledges that the EHR will face several hurdles, in the end it won’t matter if they are unhappy. To protect yourself, you make sure that others are at the table who understand and can act to overcome these problems. This means building an implementation group that includes those who will actually use the system or pass it data, such as clinicians, nurses, health techs, etc.
  • Customization. It’s a rare install that doesn’t require tailoring a system’s I/F to client needs. Customization doesn’t end with a go live, but continues through out the system’s life. Even if you’ve worked hard to insure that customized screens, etc., are useful and useable, after turnover it’s another game. Insuring the quality of follow on work after you’re done is not easy. However, you can hedge your bets by making an offer your client can’t refuse. As part of your support, come back each year to review the system. Put in any missing upgrades, etc., and give your client a punch list of issues and changes.

As with the caterer, EHR vendors face a number of problems not of their own making, but can still bite them. However, like the caterer, product vendors should take charge of their process and realize that usability may not be in direct demand, but over time can make or break the company.


November: Open Season for EHRSelector Vendor Profiles

Notice: Vendors listed on or those that want to be listed, November is open season for you to update your product profile or submit a new one.

Vendors currently listed on the Selector are:

NoVendor Product
1AllscriptsAllscripts - Enterprise
3AllscriptsSunrise Ambulatory Care
4Aprima Medical SoftwareAprima EHR + PM + RCM
5ChartLogicChartLogic EMR
6Clinical Computer SystemsOBIX
7Clinix MISClinixMD
8CureMD CorpoprationCureMD EMR
10e-MDse-MDs Solution Series
11GE HealthcareCentricity Advance
12GE HealthcareCentricity EMR
14Greenway Medical TechnologiesPrimeSuite
15iSALUS healthcareOfficeEMR
16McKessonInteGreat EHR
17McKessonPractice Partner
19NextGen Healthcare Information SystemsNextGen® EMR
20OptuminsightOptum Physician EMR
21Pulse SystemsPulse Patient Relationship Management
23Trimed Technologiese-Medsys EHR
24Vitera Healthcare SolutionsVitera Intergy EHR

To update your profile, log into your Selector account. To submit a product profile, go to the Selector”s home page, Vendor Registration. For help with any Selector issue, contact: or call 202 291 8212.

The Selector

The Selector is free for both users and vendors. There is no advertising. It has no backdoor relationships with vendors. Currently, there are about 25 vendors.

Vendors product profiles cover about 350 features. Major topics include:

  • Contract details
  • Medical specialties
  • Practice size
  • First year license cost
  • eRx functions
  • Integration of ECGs, labs, etc.
  • Interface, operating system
  • Medical record content
  • Problem list
  • Reporting capabilities
  • Standards include CCHIT, HIPAA, LOINC, etc.
  • Security, privacy

Using the system to find an EHR is easy. Clicking on one or more EHR features instantly tells you how many products match. You can then generate a full side by side report of the qualifying vendors.

We take several steps insure the integrity of submissions, for example, we only accept features that are either installed in a practice or fully available.

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