In many practices there are two ways to complete an intake. The correct way takes eleven clicks across three screens and a field that has to be found from memory. The workaround takes four clicks and a free text note a colleague will clean up later. Both produce a patient who gets seen. Only one produces a record that holds up in a chart review.
Illustrative. Within weeks, most of the team takes the shorter path.
Within weeks, most of the team is taking the shorter path. Often the most experienced staff lead the way, because they are the fastest and speed is what the day rewards. It is easy to read this as a training gap. It is more useful to read it as pricing. The system charged a higher price for the correct action, and the team responded the way people respond to price everywhere.
When the correct action costs more, capable people will find a cheaper one.
Friction is the variable
Behavior inside an operation is driven less by knowledge or motivation than by friction. Under time pressure, people choose the path with the lowest immediate cost, usually without deliberating. Every extra click, unclear field label, or step that requires finding a person instead of a screen adds a small tax to the behavior the practice wants. The tax adds up. A study in a community emergency department counted roughly four thousand mouse clicks per physician over a single ten hour shift.1
Behavioral research has shown the power of the preset path for decades. A landmark study compared organ donor consent across European countries. Where people had to opt in, consent was about twelve percent in Germany. In neighboring Austria, where consent was the default, it was nearly universal.2 The difference was not generosity. It was the design of the form.
Johnson and Goldstein, Science 2003 · same values, different form
Training does not lower the cost of the correct path. It raises awareness of a cost that stays exactly where it was. That is why the effect of retraining fades and the same finding returns in the next audit. The team knew the process all along. They were paying for it out of a budget of minutes they did not have.
The quiet that follows
A second dynamic is worth naming. Once a shortcut becomes the norm, staff stop reporting the gap, because reporting it would name their own workaround. The practice loses its early warning signal at the moment it needs it most, and silence gets read as stability. The pattern is well documented. A study of barcode medication administration identified fifteen distinct types of workarounds and traced them to the design of the system rather than to the diligence of the staff.3
Hill et al., American Journal of Emergency Medicine 2013 · Koppel et al., JAMIA 2008 · Johnson and Goldstein, Science 2003
Lower the price of correct
The design response is to lower the price of the correct action until it is the fastest option available. Human factors research in health care supports the same approach: build the expectation into the work system itself, and reliability follows.4
- Reduce steps to the minimum the regulation and standard of care actually require.
- Order fields to match the sequence of the visit rather than the sequence of the software build.
- Set defaults so the compliant selection is already in place.
- Capture documentation at the point of care rather than reconstructing it at the end of a shift.
- Structure handoffs so information travels in a format, not a hallway conversation.
- Build required steps into the tool where a step cannot be removed, so it cannot be skipped silently.
Compliance is designed into the system. What changes is not how hard the team works. It is what the day rewards. When the correct path is also the shortest, consistency stops requiring supervision, and documentation quality holds even when the most experienced person is on vacation.
Starting points
Five ways to make the right path the easy path.
- Count the clicks. Time and count the steps for your three most frequent workflows. Compare the correct path with what people actually do.
- Ask for the workarounds. Invite the team to share every shortcut they use, with no blame attached. Each one points to a design gap.
- Change one default. Pick one field or template where the compliant choice can be preset, and set it.
- Reorder one screen or form. Match it to the order of the visit. Measure the time saved.
- Recheck in thirty days. See which path people are taking now. Behavior that holds without reminders is a system.
Resources
| Resource | What it offers | Website |
|---|---|---|
| ONC SAFER Guides | Free self-assessments for safer EHR use and configuration | healthit.gov |
| AHRQ Digital Healthcare Research | Workflow and usability tools for health IT | digital.ahrq.gov |
| AMA STEPS Forward | EHR optimization and documentation efficiency modules | edhub.ama-assn.org/steps-forward |
| AHRQ Patient Safety Network | Primers on human factors and workarounds | psnet.ahrq.gov |
| IHI | Improvement tools for testing small changes | ihi.org |
Sources
- Hill RG Jr, Sears LM, Melanson SW. 4000 clicks: a productivity analysis of electronic medical records in a community hospital ED. American Journal of Emergency Medicine. 2013;31(11):1591-1594.
- Johnson EJ, Goldstein D. Do defaults save lives? Science. 2003;302(5649):1338-1339.
- Koppel R, Wetterneck T, Telles JL, Karsh BT. Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association. 2008;15(4):408-423.
- Carayon P, Xie A, Kianfar S. Human factors and ergonomics as a patient safety practice. BMJ Quality & Safety. 2014;23(3):196-205.
For educational purposes only. This is not legal advice.
The team was not the problem.
The path was.