A Fetish for Numbers
Donald A. Norman
Nielsen Norman Group and Northwestern University | norman@nngroup.com
I’m with a group of surprisingly
awake, cheery physicians and
nurses doing grand rounds on
the pediatric-care ward of one of
the best hospitals in the United
States. I’m part of a study group
for the National Academies,
looking at the ways in which
information technology is used
in health care. This hospital is
a leader: I see computers everywhere.
I’ve been spending a lot of time
in hospitals recently. No, not as
a patient, but as an observer—
following doctors and nurses on
their grand rounds, watching
patients get admitted, nurses
doing shift changes, pharmacists
filling prescriptions, and then
watching nurses actually deliver
the prescribed medication to
their patients, waving bar-code
readers over the prescriptions,
the medication, and the patients.
We walk down the hall toward
the first set of patents. We are
quite a crowd: the attending
physician and approximately
five medical residents, physicians completing the last stage
of their training, plus one or two
nurses. The attending physician is responsible for treating
patients and is also supervising
the residents, each of whom is
wheeling a computer cart. The
hospital calls them “COWs”—
Computer on Wheels. (One hospital switched the name to WOW,
Workstation on Wheels, after a
patient heard physicians outside
her room talking about “the cow”
and thought they were referring
to her.) A COW is a chest-high
cart with computer screen and
keyboard at a height appropriate
for stand-up reading and typing;
the computer itself and batteries are located at the bottom of
the unit. Five COWs, plus a nurse
wheeling a big filing cabinet of
papers, plus the attending physician, plus the members of my
observation team. We take up
a lot of space. We stop at each
patient’s doorway to review
progress. The attending physician asks for a review, and each
of the residents flips through the
windows displayed on their computer screen and summarizes
status: “Calcium level is fine,
white count low.” Each resident
has different information for the
patient, or to be more precise,
has screens that describe test
results from different laboratories.
The patient was a bunch of
numbers. Moreover, the numbers
were not organized by symptoms or diagnoses: They were
organized by what tests were
run and which laboratory within
the hospital had processed the
results. The patient’s history, the
record of past events and health
care, was in a different location
from current test results. Current
results were in a different place
than past results. Different hospitals might have different laboratories, so their results would
be organized differently. But the
attending and resident physicians and nurses were experts at
piecing together a mental model
of the state of the patient from
all these numbers. Or so they
said: Evidence is difficult to come
by.
“That’s interesting,” I said to
myself, stepping into a room
filled with displays. There were
multiple infusion pumps, multiple computer readouts, and multiple monitors. The entire room
was filled with the red glowing
lights of display readouts and
the dim white of graphs on the
computer screens. “Fascinating,”
I said. “You’ve brought all of the
monitors into one place so you
can see how all the patients are
doing.”
“No,” said one of the physicians, “what do you mean?”
“So where are the patients?” I
asked, expecting to be told that
they were in rooms adjacent to
the instruments.
“Right there,” said the physician, obviously puzzled by my
question. “Right there in the
room, right in front of you.”
I looked closely and still
couldn’t see a patient. One of the
nurses walked over and pointed.
“Oh,” I said.
There were so many medical
devices, so many readouts and
displays, that I could not even
see the patient until someone
showed me. Now, this was an
infant ward, so this particular
patient was tiny, but even so, it’s
a good illustration of modern
