But the EHR interface dominates
Why sub-optimal design of the EHR interface throttles the clinical consultation
Dave Pao
2 min read
November 2023
'We have [electronic] medical records, but they are like the shadows on the wall of a cave, punctuated by codes and jargon.’
- Dr Glyn Elwyn (2014)
The Electronic Health Record (EHR) interface is the cornerstone tool of the clinical consultation, through which clinicians review, collect, interpret and curate patient data.
The consultation is not a pre-determined, nor linear, sequence of tasks. Rather, it is an unfolding, unpredictable and often unstructured conversation. It is only following this conversation that tasks—such as ordering blood tests and imaging investigations, or prescribing treatment—can begin.
For the patient, the consultation can be considered a liminal space where transformation often occurs. This space is suspended between the 'what was' and ‘the next’, health and illness, safety and fear—which can pivot dramatically on a single piece of data.
For the clinician, the consultation is an exploration of that exact same worldview, additionally anchored to each patient’s clinical data landscape. The consultation ‘has been and remains a keystone of care: the medium in which data are gathered, diagnoses and plans are made, compliance is accomplished, and healing, patient activation, and support are provided.' (Lipkin et al. (Eds), 1995).
The EHR interface plays a central role in the consultation: a significant presence that can be thought of as a collection of ‘silent but consequential voices’ (Swinglehurst et al., 2011). There is no doubt that the EHR has agency in the sense that, expressed simply, an agent is ‘one who acts.’
The Personal Health Record (PHR), which offers patients the ability to access and contribute their own health data, is yet another agent in the consultation.
This means that there are at least three simultaneous, interdependent 'conversations' (see video):
(1) The clinician has a conversation with the EHR interface, usually before meeting the patient, to assimilate clinical information that includes the patient’s lifetime narrative history and clinical data. This is typically an explorative process. In real time, the clinician then has to contextualise these data to the patient and their current health needs, and input further clinical information, interpretations and agreed outcomes back through the EHR interface.
(2) The patient will likely have their own conversation with their own PHR or health app(s). This is typically an explanatory process. Apps are typically not integrated with EHRs, and PHRs only sometimes. Often, the patient will be in conversation with their companion or advocate.
(3) Only after the clinical data landscape is adequately known, can the clinician begin an informed conversation with the patient. This is the primary conversation flow that engages with the existential concerns of the patient. Supporting this conversation is the deeper goal of the EHR interface, and where the work of the clinician truly lies—beyond the data.
In the real world, it is the throttling of the first of these conversations (1) that most damages the clinical consultation. The precision, richness and fluidity of the interaction between the clinician and their EHR interface directly determine the quality of clinical care. Inaccurate, imprecise, corrupted, misinterpreted, mis-curated, missing, misplaced, displaced, duplicated—or simply unintelligible—data ripple through the EHR to impact every facet of a healthcare system.
It is this conversation that my research addresses.
Elwyn, G. (2014). ’Patientgate’—digital recordings change everything. BMJ, 348, p.2078.
Lipkin, M., Jr et al. (Eds). (1995). The Medical Interview: Clinical Care, Education, and Research. New York, NY, USA: Springer.
Swinglehurst, D., Roberts, C. and Greenhalgh, T. (2011). Opening up the ‘black box’ of the electronic patient record: a linguistic ethnographic study in general practice. Communication & medicine, 8 (1), pp.3–15..
