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EMR Usability Point Difference, Us vs Them in EHR Adoption, and EMR Companies Don’t Care About Usability

Posted on July 7, 2013 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I can’t believe there’s a 30 point difference in usability. Really? No, I’m not talking about the difference. I’m talking about trying to put a number on EMR usability. Think how ridiculous that idea really is. An EMR is made up of 100s of functions and you’re going to take an EMR vendor’s usability and try and quantify it to a number. That’s just insane.

This is an awesome point that really highlights a bunch of the key challenges that happen in EMR implementations. There’s definitely a lot of blame and finger pointing that can happen. You have to battle against this for it not to happen.

This is a great article that can be summed up with: because they don’t have to care. That’s right. EHR sales are doing just fine, so they don’t have to worry about usability. Healthcare really has reached a point of acceptance of crappy technology. This will change one day, but I don’t see it changing at least until after meaningful use.

User Experience is Hot HIT Topic with Good Reason

Posted on April 18, 2013 I Written By

As Social Marketing Director at Billian, Jennifer Dennard is responsible for the continuing development and implementation of the company's social media strategies for Billian's HealthDATA and Porter Research. She is a regular contributor to a number of healthcare blogs and currently manages social marketing channels for the Health IT Leadership Summit and Technology Association of Georgia’s Health Society. You can find her on Twitter @JennDennard.

User experience in the world of healthcare IT has never been a hotter topic. It seems not a day goes by that I don’t come across an article, blog, tweet, or outright rant regarding the state of user friendliness, especially with regard to EMRs. (Who can forget the American Medical Association’s note earlier this year to Farzad Mostashari, peppered with complaints about physician usability of EMRs?) I see plenty of negative coverage around the topic – plenty of folks like to have a soapbox to stand on, after all.

I don’t, however, see enough coverage devoted to businesses and providers working to make the backlash better. Surely there are unsung heroes out there in the world of HIT UX that are at their drawing boards right now, attempting to take the sting out of those extra clicks, and listening with bated breath to providers’ complaints and praises.

I came across one such story in New Orleans a few months ago, where, like many of you, I tried to successfully drink from the fire hose (bottled water, actually) that was HIMSS13. I was able to sate my thirst for good UX news at the PointClear Innovation Awards breakfast, which honored a select group of the company’s clients for their work in the realm of user experience.

McKesson took home top honors this year, and while I had some knowledge of their work in the area, I didn’t realize how great of an emphasis they have placed on making sure their healthcare IT solutions are used in the most optimal way for the best possible patient outcomes.

“The big dynamic we are trying to tackle is around critical decision makers,” explains Bobby Middleton, Executive Director, Enterprise Intelligence Product Management at McKesson. “Through experience with our customers and continued research, it is becoming very obvious that our healthcare leaders are often put in a position to make critical decisions without pertinent, relevant and timely information.

“Our Enterprise Intelligence solutions are all geared around providing the right information to the right person at the right time,” he adds. “Our User Experience research is being used to make sure the targeted offering we are delivering via these solutions help a specific set of critical decision makers make the right decision. It is going great so far, and really allowing our technology teams to connect with their end consumers.”

I wonder if we’ll start to see more positive publicity of efforts like McKesson’s, especially as Stage 2 draws closer, more and more providers consider switching to more mature EMRs, and next year’s predicted influx of the newly insured start to clamor for greater digital engagement options and price transparency. One less click or toggle may just make all the difference when it comes to quality patient care.

One Doctor’s EMR Usability Wish List

Posted on March 18, 2013 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

In this space, we talk a lot in the abstract about how physicians feel about EMR usability. Today, though, I wanted to share with you some great observations from a piece by an angry anesthesiologist who lays out her own usability wishlist for EMRs and health IT generally.

In the piece, Dr. Shirie Leng fumes over the sheer work it takes for her to negotiate the systems she uses at her hospital. She notes that over the course of doing eight cases during a day, she’ll a) sign something electronically 32 times, b) type her user name and password into three different systems a total of 24 times and c) generate about 50 pages of paper given that the the computer record must be printed out twice.

To Dr. Leng, there’s ten steps institutions can take to eliminate much of the hassle and waste:

1. Eliminate user names and passwords:   She suggests using biometric sign-in technology.

2. Eliminate the paper:  Why print data that’s already entered into the system, she asks?

3. Make data systems compatible and 4. Make everyone statewide use the same system:  Dr. Leng says it’s crazy that we don’t have interoperability within hospitals or between different institutions.

5. Don’t make her turn the page:  “All the important information about a patient should be on the first page you open when you look at a patient,” she says. “I shouldn’t have to click six different tabs.”

6. Don’t make her repeat herself: If she does several cases the same way, with the same documentation each case, don’t make her re-enter it every single time.

7. Invest in voice-recognition software:  During patient interviews, Dr. Leng notes, she wants to look at patients and talk, not hunt and peck at the keyboard or worse, spend hours later typing in data or clicking checkboxes.

8. Go completely wireless:  Not an EMR point, but a good one nonetheless: why make doctors untangle cords and monitoring wires?

9. Hire a typist if you need one:  Don’t turn nurses into data entry clerks, she argues. Right now they have massive amounts of data entry piled onto their plate.

10. Triple back-up the system:  Paper doesn’t crash but computers do, she notes.

So there you have it, a list of EMR and health IT concerns straight from a practicing physician. I think all her points deserve attention.

Do EMRs Force Doctors To Draw Conclusions?

Posted on February 4, 2013 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Today I was reading a column by the inimitable Mr. HISTalk in which he argued that EMRs really can do a major disservice to patients.  One way in which they do so, he suggests, is inherent in their design:

“EMRs try to turn freeform and sometimes tentative thoughts into dropdowns and template-driven generic verbiage that may destroy their original context (that’s what programmers do: impose order and create retrievable database information, so it’s not really their fault).”

I found this to be pretty interesting, because it highlighted a problem not discussed a lot in this space. To wit, it points out that dropdowns, templates and the like aren’t just frustrating — they’re actually forcing doctors to document care in pre-prescribed ways which may or may not suit the physician’s line of thought.  After all, in a template-and-dropdown environment, there’s little room for thinking out loud, suggesting theories or making unorthodox observations.

Ideally, the notes physicians enter or dictate should represent the best of their judgment, but also their intuition. Not only is intuition necessary to determine the best course of care for patients, it’s a critical tool for divining when something is out of order, be it a test result, the patient’s current diagnosis or something in the history that doesn’t fit.

And here you have the essential conflict between EMR-driven medicine and “old fashioned” methods.  As Mr. HISTalk points out, it’s the job of the EMR makers to normalize data such that it can be abstracted, shared and studied.  But it’s the job of the doctor to solve the problem that shows up in front of them, whether it can be described easily using a template or not.

Now, I’m not suggesting, as many have, that EMRs can’t be evolved into tools which are flexible enough to both support physicians’ process.  But I do think it’s important to focus in on issues like these, as they’re still very much in play.

When The EMR *Is* The Problem

Posted on January 25, 2013 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

The other day, I sat in an office while a nurse practitioner entered data into an EMR.  The visit was a follow-up, so there wasn’t a lot to record, but somehow, it took a good 45 minutes nonetheless.  While the nurse’s long stenciled fingernails couldn’t have helped her typing speed much, the real problem seemed to be the EMR, which kept locking up and seemed to be harboring someone else’s data. (It had my weight at 50 plus pounds more than I am, a data problem to be avoided if you’re hoping to track patients for health risks.)

Now, I do think some of the responsibility for the crazy quilt of mistakes and processing problems can be laid at the feet of the nurse, who didn’t seem particularly well oriented to the system and as noted, clearly couldn’t have passed a high school typing test. I also doubt she had to mispronounce my name three times as she moved from one screen to another.  Clearly, she wasn’t big on bedside (office-side?) manner.

The thing is, I think she wanted to be helpful, wanted to be personal and most importantly, wanted to be careful with the interview and med prescriptions. The problem was, she was so embedded in the process of using the EMR that the higher purpose of having it there in the first place was all but lost. Though she seemed bright enough, the nurse had trouble compensating for the demands of the system.

The bottom line, as I see it, is that even if the nurse will never win any IT prizes, the situation was not her fault.  It was that the EMR absorbed all of the nurse’s attention and concentration, leaving me feeling somewhat peripheral to the situation at best. Yes, she could probably make some improvements in how she interacts with patients, but if taking her eyes off the screen means she forgets critical details, that’s not going to happen.

This experience left me wondering: How often are good clinicians being turned into distant, vexed and struggling professionals who barely acknowledge that the patient is there twiddling their thumbs?  And how can the health system afford this kind of timewaste and error-prone user patterns?  I don’t know the answer to either question but I think we should find out.

Some Interesting EMR Usability Ideas

Posted on December 20, 2012 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Not long ago, I wrote a piece slamming the lack of EMR usability standards out there today, arguing that the industry was pretty much going to stay in a rut until we got some.  One of our readers, Prasad Patankar, posted a very thoughtful response which I felt deserved more exposure and discussion.

Here’s his ideas, in italics, with my comments interspersed:

* EMR systems should have a consistent hierarchy for navigation so
  that it is easy for users to locate information.

This is hard to argue. Unfortunately, given the vendor turf wars going on out there, I think we’re going to be stuck with proprietary systems and proprietary hierarchies for some time to come.  But what Prasad suggests here is just common sense, not that we can expect to see a lot of that on display.

* Error messages should be clear. They should explain why the error
  occurred and explain what the users should do next. Definitely not
  any programming language errors.

Again, I agree with Prasad here. This kind of consistency would do much to orient users. The problem is, these systems are still driven largely by developers, who best understand the nasty programming language error codes.  Expecting them to make their EMR products speak plain English is a bit of a stretch, sadly.

* For screens that contain too much information, there should be an
  option available for the users either to see the summary or a
  detailed drill-down capability. Some EMR vendors have started
  incorporating this functionality into their reporting modules.

Beautiful — a function vendors already understand. That’s enough to sell me on the notion that it can be more widely implemented, and soon. In this case, there’s no excuse for vendors to obfuscate;  just go ahead and make the data easier to read already!

* Consistency should be followed in displaying allergies and current
  medications in one single location. Users should not have to click
  multiple windows to get to this. This also applies to past
  encounters(progress notes) which have been migrated prior to
  implementation of the new EMR system.

This is a very good idea. When Your Editor recently read up on research into errors made using EMRs, medication slip-ups were by far the most common event. (And the only event that created serious harm was administration of a drug to which the patient was allergic.  Past notes might not be as urgent, but useful, definitely.

* It would also be interesting to see if EMR vendors could incorporate
  the cultural context and meaning of a color in that context before
  they use the entire color palette in their software.

This is an intruiging idea, though I can’t imagine the big enterprise vendors giving it much thought.  Perhaps if Apple designed their interface… But that’s a tale for another day.

Where Are Usability Standards For EMRs?

Posted on December 7, 2012 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

The other day, I was talking with a physician about ambulatory EMRs.  “None of them are any good,” said the doctor, who’s studied EMRs for several years but never invested in one. “I can’t find a single one that I can use.”

Are any of you surprised to hear him say that? I’m certainly not.  Perhaps he’s exaggerating a bit when he says that absolutely none are usable at all, but it’s hard to argue that doctors cope with a counter intuitive mess far too often.  And of course, enterprise EMRs get if anything lower usability ratings from practicing doctors.

All of which brings me around to the notion of EMR usability standards, or rather, the lack of such same. While those in the industry talk often about usability, there’s no real consensus standard for measuring how usable a particular EMR is, despite noble efforts by NIST and impassioned advocacy by usability gurus in the field.

Certainly, private research organizations take usability into account when they survey clinicians on which EMRs they prefer. So clunky EMRs with lousy UIs do pay some kind of price when they’re rated by the clinical user. But that’s a far cry from having a standard in place by which medical practices and hospitals can objectively consider how usable their preferred EMR is going to be.

So, why don’t we have usability standards already in place?  The market still hasn’t punished vendors whose EMRs are a pain to use, so vendors keep on turning our products built around IT rather than clinical needs. The doctor I spoke with may have opted out of the EMR market, but most providers aren’t going to do that, Meaningful Use incentives being just one reason why. (It’s a “handwriting is on the wall” thing.)

It’s a shame CMS isn’t pushing vendors to produce Meaningfully Use-ABLE EMRs. That might do the trick.

NIST’s EHR Usability Conference Breaks Both Old Ground and New Focuses on EMR Patient Safety Protocol

Posted on June 14, 2012 I Written By

When Carl Bergman isn't rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manager doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst, a role he recently repeated for a Council member.

Regular reader, Carl Bergman from EHR Selector, attended the recent NIST EMR Usability Conference and sent over the following guest post on what was said. Thanks Carl for sharing your experience with us.

A year ago last June I attended NIST’s (National Institute of Standards and Technology) conference on EMR/EHRs usability. [See Carl’s post on the NIST EHR Usability Conference from 2011.] It was a mixed bag. There were several excellent presentations on the fundamentals of usability, how to analyze an EMR and where the field was headed. Unfortunately, NIST’s staff took a narrow view confining their work to EMR error conditions and assiduously avoiding interface, workflow and clinical setting issues. It was odd that an agency that prided itself on redesigning nuclear control rooms after Three Mile Island or the design of airplane cockpits would ignore EMR user interfaces.

New Approach: New Protocol

At this year’s conference at NIST headquarters in Gaithersburg, MD, the past was not prolog. Last week’s conference focus was on a comprehensive EMR usability protocol, NISTIR 7804, that NIST produced last February. (For a good synopsis, see Katherine Rourke’s Design Errors That Cause Patient Harm per NIST.) NIST’s staff pulled together a notable group of speakers on patient safety in general and implementing the protocol in particular. (NIST is posting the presentations here.)

The protocol, designed to review an EMR, is not a trivial undertaking since it has about 180 line item questions. It asks, for example, if the EMR:

  • Keeps patient identities distinct from each other? That is, does the system prevent one record from writing over another or erroneously sharing data elements?
  • Lays out pages in a consistent manner using color, icons and links identically?
  • Uses measurements consistently? That is, if weight is entered in pounds and ounces in one place, do they show that way in other places?
  • Displays fields fully rather than being truncated?
  • Sorts logically based on the subject?
  • Show dosages, etc., with all needed information on the page?
  • Displays multipage entries or lookups with proper navigation choices?
  • Has error messages that state what is wrong and how to cure the problem?
  • Accommodates different levels of user knowledge? That is, does it have extended help for novice users, refresher information for occasional users and short cuts for experienced users?

Developers Present in Force

If NIST’s major intent was to get developer attention, they succeeded. Of the hundred or so attendees, about 20 percent were from major systems. 3m, Allscripts, Athenahealth, Centricity, McKesson, NextGen, etc., each had one or more representatives present. Others present included Kaiser, HIMSS, Medstar, First Choice, ACP, Columbia, etc.

Unfortunately, there is no way to know developer reaction to the protocol. The conference had no comment session. I don’t know if this was by design or if time just ran out. NIST staff did indicate that next year the conference would be two days rather than one. However, a year is a long time to wait for reactions. This is especially pertinent since NIST is not a regulatory agency. Its protocols are strictly voluntary and depend on vendor acceptance.

What NIST did do is offer several presentations that emphasized how fragile patient safety can be in an HIT world. One breakout session used an actual, unnamed product’s screen that had dozens of misleading or ambiguous fields. For example, the screen’s fields cut off drug names, used red to indicate several different findings and used a pop up that blocked a view of a pertinent entry.

In another more broadly based patient safety presentation, University of Pennsylvania’s voluble Ross Koppel drove home how common elements in EMRs such as blood pressure – he’s found 40 different ways to show it so far – are subject to many formats for capture and display. Moreover, if you think EMRs have problems, Koppel shows how bar codes and work arounds can play havoc with workflow and patient safety.

Wanted: One Good Policy Compass

For those of us possessed of an EMR design demon, it was both a good chance to wonder out loud just what it all meant and where, if anywhere, things were headed. Sadly, the most common answer was who knows? There were some common points:

  • It’s better to have NIST’s protocol than not.
  • You can forget the FDA playing a bigger role. It’s under funded and over worked.
  • HIMSS will wait for the industry and the industry has shown no hurry.
  • EMR adverse incident reporting would be great, but who would do it and how open would it be?

In short, if you’re shopping for an EMR, regardless of your size, don’t count on anyone handing you a usability report on an EMR anytime soon. Moreover, don’t try to run NIST’s protocol on your own unless you have full access to the proposed EMR, lots of time on your hands and a good grasp of the protocols details.

There are some things you can do. You can ask potential vendors questions such as these:

  • Have they run the NIST protocol and what did they do as a result?
  • If not NIST, do they have a written usability protocol and, if so, can you see it? How have they implemented it?
  • Have they tested their EMR’s usability with outside, independent users? What were the results?
  • Have they used any interface designers?
  • What usability changes do they plan?

There is no guarantee that you’ll get a great product, but it could mean that you get one that doesn’t bite your patients or you.

Better EMR Design

Posted on May 23, 2012 I Written By

Priya Ramachandran is a Maryland based freelance writer. In a former life, she wrote software code and managed Sarbanes Oxley related audits for IT departments. She now enjoys writing about healthcare, science and technology.

Now that we’ve heard the statistics about EMR use, we’re also hearing a lot of opinions on EMRs, and not all of them are laudatory. In fact I read some separate articles recently, and they pretty much said the same things in so many different words:

– EMRs are not intuitively designed. They do not reflect actual workflows that most doctors or hospitals follow. Rather the applications look like they’ve been designed by a bunch of programmers who then design the UI to look like how they’re underlying data are structured.
– Because they’re pretty much being foisted on hospitals and doctor’s offices through “incentive” programs, often the resources expended on them are sunk costs. To improve the workflow of a software to accurately reflect the needs of a particular hospital, you will need to pump extra money into it. That’s about as likely to happen as a software vendor providing you a customized solution without charging you anything extra.

Let me assure you – the medical establishment has it exactly right, at least in my experience. I work as a technical writer, so much of my working life consists of documenting the products that make it to your doorsteps, and I have experienced some of the same frustrations as you. I’ve complained about them, made myself unpopular with development teams and added my two cents to feature request lists, just like many of you.

But, I also see things from a programming perspective too, and I’m here as a sort of ambassador between both worlds. Many teams I worked with had an actual designer working as part of the team.
But the designer’s role was often making the colors look attractive enough, or the font large enough to appeal to a cross-section of users. One of my old bosses, different industry and everything, called this our Lipstick on a Pig game, and plenty of times that’s what the designer’s role was. Inventing plenty of shades of lipstick for the proverbial pig.

Ergonomic design was not what the designer was tasked with doing. One place I worked at even had a doctor on payroll. Except he had a doctor’s degree from Shanghai, had not cleared his exams in the States and had no idea how medicine is practiced in the States. It sure looked good on paper when their sales team went out to clients and talked about having a dedicated doctor on staff to help with software design.

And the effect of poor design on functionality is often perplexing, sometimes disastrous. Case in point – documenting all the drugs administered to a patient. It has been drilled into programmers that clicks are sacred things, you don’t want doctors wasting too many of them.

So because we don’t want too many clicks, we list each and every medication a patient has been administered, add some pagination logic around it and call it a day.

The doctor, who is the end user, for whom we designed this software system, now sees all the information in a “convenient” list and doesn’t need to open up a medication tree to view the medications under it. Except if she has a very sick patient with multiple encounters, the case history reveals a medication that is 31 pages deep. To get to Xanax, she might have to page through 30 previous pages.

While these “features” fall into the realm of merely annoying, they’re nowhere as disastrous as those modal alerts that Barbara J. Moore talks about in her KevinMD piece. A modal window is one of those annoying windows that you have to take an action on, otherwise you can’t proceed any further in your workflow. Moore points out the hazards of such alerts which force a doctor to take a choice, any choice, but aren’t available later if the doctor wishes to review the alerts at leisure.

So yes, software vendors need people who know the workflow to design the systems. But more importantly, you – the medical establishment – must keep requesting changes or suggesting features, or vendors will remain complacent about what they put out.

Are “User” And “Process” – Centered EMR Design On A Collision Course?

Posted on April 3, 2012 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Most of the critiques I read of EMR design ding the EMR for its difficulty to use or its inability to accomodate the workflow of the institution that bought it — and of course, sometimes both. What I’ve never heard suggested, however, is the following idea proposed by Chuck Webster, a guy who clearly doesn’t stop short when he decides to study something. (He’s an MD, an MSIE and an MSIS in intelligent systems design, which is only one of the reasons I think he’s onto something here.)

In a thoughtful and nuanced blog entry, Dr. Webster outlines the work of a pioneer in usability design, Donald Norman, and comes away with the conclusion that the current trend toward “human-centered design” might actually be a mistake.  What a pain — health IT limps along catching  up with a trend from the 1980s, and now may be too late to catch the bus.

In any event, Dr. Webster argues instead of focusing on human/user-centered design, EMR vendors should be focused on activity- or process-centered design. I love what he says about one of the potential problems with human-centered UIs:

Optimization around a user, or user screen, risks the ultimate systems engineering sin: suboptimization. Individual EHR user screens are routinely optimized at the expense of total EHR system workflow usability…I’ve seen EHR screens, which, considered individually, are jewel-like in appearance and cognitive science-savvy in design philosophy, but which do not work together well.

It’s better, he suggests, to have EMRs model “interleaved and interacting sequences of task accomplishment” first and foremost. For example, he writes, key task collections that should be considered as a whole include workflow management systems, business process management, case management and process-aware information systems.

While there’s much more to say here, of course, I’ll close with Dr. Webster’s words, who once makes his point with wonderful clarity:

User-centered EHR design does help get to good EHRs. Good isn’t good enough. If EHRs and HIT are going to help transform healthcare they need to be better than world-class (compared to what?). They need to be stellar. Traditional user-centered design isn’t going to get us there.

The question I’m left with, readers, is whether you can have your cake and eat it too. Does one side of UI/UX design literally have to be jettisoned to support the other?