What Wayne Gretzky Can Teach Us About Fixing Our Health-Care System

In getting doctors to adapt to new medical technology, designers can learn a lot from the ice hockey legend.

In my last post on Co.Design, I wrote about how mandatory implementation of electronic medical records (EMRs) technology is forcing highly skilled physicians out of practice. The trend is primarily affecting the older generation of physicians, who didn't grow up with computers. These doctors aren't used to interacting with a big screen between them and their patients, and the technology hasn't been designed to be user friendly.

Some doctors will spring in to action and get on board with the EMR system, as the government will begin levying fines on medical practices where physicians don't. But others will quit altogether. And we'll lose an unknown percentage of our top medical talent.

There's a shortsighted assumption held by many in the health care community that the use of EMRs will get easier when the older generation is gone. On a purely human level, there's something wrong with this strategy of morbid attrition, where we're waiting for the old dogs to die out so the system can be based around new tricks. But the "change, pay up, or quit" approach we're taking to designing and implementing EMRs is backwards for highly practical reasons, as well. The older generation may be affected the most, but when they're gone, all the same problems will still exist.

It's not just an old person's thing

I understand the conclusion that EMR technology is just an old person's problem. There is a non-debatable correlation between how old a doctor is and how much they struggle with EMRs. Many have poor typing skills, a lack of familiarity with conventional user-interface elements like drop-down menus, even discomfort with a mouse and keyboard. The older you are, the less new things seem "new" and the more they seem "newfangled." No surprises here.

Older physicians may be the proverbial "weakest of the herd," but there's a deeper problem at work: We seem to think it's OK to create technological monstrosities that fundamentally change the way people do their jobs, and then expect them to adjust accordingly.

Don't force it

Why do so many doctors and practices use these systems? Because they'll be fined if they don't. But behavioral economics research clearly shows that there are many more effective incentives than fear of punishment. Simply put, everyone should want to use an EMR because it makes his or her practice better, safer, and more efficient.

Gretzky's broader point applies to the design of complex UI's.

It doesn't work when dictators impose their will on people, and it doesn't work when technology does, either. It has been estimated that 20-30% of EMR systems are uninstalled within a year, often due to physician dissatisfaction. Think about it: You'd have to be really dissatisfied to uninstall a system that costs around $120,000 per doctor to implement. With that in mind, it's not hard to infer that lots of doctors are living with systems they wish they could afford to replace. Physician acceptance is essential to the functioning of the system, and the design community needs to step up and make an impact there.

Play where the puck is going to be

There's a great quote attributed to Wayne Gretzky, which he supposedly said when a journalist asked him why he was such a great hockey player. It goes something like, "A good hockey player plays where the puck is. A great hockey player plays where the puck is going to be." I suspect that he wasn't thinking about information systems when he said it, but there's a broader point to his message that applies to the design of complex user interfaces, because of a thing called Moore's Law.

If you're a geek like me, you probably already know Moore's Law. You may even own a T-shirt with a humorous saying about it. If not, here's the upshot: Computational power has more or less doubled every two years since the mid-20th century and will continue to do so until 2020 or later. One of the consequences is that it becomes increasingly cheaper to make more technologically complex products. In short, the amount of technical complexity foisted on consumers is only going to get worse, and it's going to happen faster than it ever has.

So, yes, I agree that when the medical old guard retires, dies, or quits, the remaining physicians will be more comfortable with today's technology. But at that point, we'll just be playing where the puck is.

We've seen it in every domain, where technological change is happening faster and faster. Moore's law says that the rink we're playing on is on the side of a very steep hill, because not only is the puck moving, it's accelerating.

Too old for technology?

To be clear, this isn't a manifesto on designing for old people. It's a manifesto on designing for people. My point is that with technological innovation getting faster, the age at which you're "too old for technology" is going to get increasingly younger, or you'll be forced to change your life around more and more frequently to fit the needs of a new system.

The only way to keep up with the puck — or Moore's Law — is to design for what isn't changing anytime soon: human nature. We'll drive adoption up, training costs down, and realize more of the benefits EMRs promise if we do. It all comes down to a fundamental truth about people: We are great at adapting when we want to, but we absolutely hate being forced to change.

We're great at adapting when we want to, but we hate being forced to change.

Electronic medical records represent an incredible technology with nearly limitless potential. I truly believe in their importance to fixing health care. They just need to be done right. And "right" means using design to break technology to the will of the physician, as opposed to using training to break physicians to the will of the technology.

But the fact remains that less than 20% of doctors actually use fully functioning EMRs (some studies say as low as 4%, some as high as 17%). And at the end of the day, that low of an adoption rate is plain bad for business.

Doctors don't want to use EMRs, per se. They want what they pulled 100-hour weeks in med school for: outcomes. They want to keep healthy people healthy and make sick people better; they want to prevent errors that hurt their patients and jeopardize their careers; and they want to look their patients in the eye, understand what they feel, and use their intuition. And being able to streamline billing, improve research, and reduce cost doesn't hurt either.

If EMRs can deliver all of those outcomes without requiring people to completely shift the way they do their work, then everyone wins. If they can't, we'll only get the early adopters to change willingly, and we'll have to pull everyone else kicking and screaming. I think we can get where we need to be someday, but not without an attitude adjustment.

[Top image by Jim Frost]

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  • TMJR

    Nice article.  I liked your interpretation of Moore's and Gretsky's laws.  Very clever way to make smart points about anticipating and designing around practical points of convergence of user needs, user abilities, and technological capabilities.

  • Dlafky

    There is a certain vein of youthful
    arrogance that arises from lack of perspective. In the case of Mr. McMullen’s
    article, it is clear that his thinking is informed by the moment and not by any
    sense of the history of technology or the study of technology adoption.

    The very fact that Mr. McMullen is able
    to make a blog post is a testament to the ingenuity and vision of two
    generations of technology pioneers. The Internet works because of Vint Cerf
    (age 69) and Bob Kahn (age 73). Without their genius, Tim Berners-Lee (age 57)
    would not have had an infrastructure to inspire him to create the World Wide
    Web. Without the Web, there would be no “I” anything for Steve Jobs (d. 2012 at
    57) to design around.

    Mr. McMullen may not be aware that Moore’s
    Law, which he condescends to explain to his reader, speaks to the work of
    Nobel-winners John Bardeen (1908-1991), Walter Brattain (1902-1987) and William
    Shockley (1910-1989), whose invention of the transistor made possible the rapid
    miniaturization that Gordon Moore (age 83) foresaw and described in his 1965

    All of these achievements, and many more
    which are too numerous to detail, represent the shoulders of giants on which the
    internet-enabled technological world now stands. It is sad to behold the
    trivial uses to which these profound inventions have been put. Coupons, gossip
    portals, temples of self-regard.  I think
    these are not what the Founding Fathers of the Internet Age had in mind.

    In Diffusion of Innovations,
    Everett Rogers (1931-2004) laid out a useful model of technology adoption. He
    and his collaborators defined the categories with which all of us working in
    technology are familiar: innovators, early adopters, early majority, late
    majority, and laggards. Rogers avoids the common mistake of McMullen and others
    to stereotype adoption behavior on the basis of demographics. It is quite clear
    from the evidence that age, gender, income, and education have little to do
    with an individual’s embrace of new technology. There are laggards among old
    and young, male and female, rich and poor. To assume that those over a given
    age are always going to be laggards, and to write them off as a group, is both naïve
    and unfair.

    But to return to the idea of perspective
    and its importance in a person’s worldview: it is not stereotyping to note that
    the shorter one’s tenure on the planet, the fewer events and developments one
    will have seen. It is only over time that one observes the connections among
    events—the breadcrumbs leading from one development to another. It is no slight
    to youth to mention that, unless they have been taught about these breadcrumbs
    by their predecessors, they will know nothing of them and thus their observed
    experience will be that that which is here has always been here.

    I’m pleased to count myself in the 1955 age
    cohort of Steve Jobs, Tim Berners-Lee, Bill Gates, and Grady Booch. All of
    these extremely talented technology leaders knew who their forbears were,
    understood the debt they owed and paid respect. In time, when the arrogance of
    youth fades, the new generations of those network-connected from birth will come to
    appreciate that whatever their achievements are to be, they are only possible
    because of the brilliance of those they now deign to call “dinosaurs.”


    Lafky, Ph.D., MSIS, CISSP

    B. Sc. Carnegie-Mellon
    University, 1977