Make the EHR better: a video introduction

November 2023

‘He may be any of a number of things; he will not be all of them. He may be well versed, he may be a poet, he may be a creator in one or more than one science; he will not be all kinds of man or all kinds of scientist; and he will be lucky if he has a bit of familiarity outside the room in which he works.’

- Robert Oppenheimer, BBC Reith Lectures (1953)

To me, a curious clinician, that we live in a world of silos has never been more apparent than in the disciplines that contribute to the design of Electronic Health Record (EHR) interfaces. It is hard to think of a worse design dystopia where fragmentation has trumped collaboration. The emergence of new, increasingly specialised disciplines brings a narrowing of territory, a guarding of boundaries, an unnaturalness to collaboration—and a diminished weight of collective responsibility.

There is no denying that increased specialism results in innovative research output and new knowledge. But a lot of effort seems to focus more on defining new discipline horizons—through theories, frameworks and taxonomies—rather than refining existing ones. Even though user-centred, human-centred or participatory approaches are at the heart of most EHR interface design disciplines, the clinical horizon has become lazily, or ignorantly, subsumed within their own horizons.

Neri Oxman (2016) critiques these boundaried disciplines when she says, 'if you’re a citizen in one, you’re a tourist in another.' In her PhD thesis she presents the 'anti-disciplinary hypothesis: that knowledge can no longer be ascribed to, or produced within, disciplinary boundaries, but is entirely entangled.'

I submitted my proposal for this PhD after a new EHR system replaced paper records in the London teaching hospital clinic where I worked. On the Monday morning of ‘Go live’, after yet another dreaded login screen, my first patient was a man I’d never met before but had been a patient of the HIV clinic for 18 years. Before being of any use to him, I needed to understand at least an outline of his history—which the EHR interface could not provide. In response to my repeated interrogation he gestured to the EHR screen with the question patients commonly ask: ‘Isn’t it all in there somewhere?'

It was all in there, somewhere. The moniker 'Write Once, Read Never', or WORN, remained perfectly apt twenty years after it was coined in The Lancet by Powsner and Tufte (1994)—a clinician and statistical artist, respectively. This first patient was just the start of a digital morass that saw my clinic finishing three hours late despite having half the usual number of patients in it. You might think things have come on since then—but they haven’t really, not in the fundamental way EHR interfaces support how clinicians think.

‘My first EHR’ made me wonder how much designers of the EHR interface actually care about the clinician user experience. My conclusion, at the end of this research journey, is that they want to care more than anything else—user-centredness is, after all, a time-honoured and beautiful design tenet. Clinically appropriate EHR interface design has the potential to transform the working lives of clinicians (and indivisibly, patients), allowing them to practise at the top of their game rather than struggle under unnecessary cognitive load.

Ultimately, in my view, the lack of a common language that connects design and medicine—helping design practitioners understand clinical practitioners, and vice versa—is, hands down, the largest knowledge gap that this research addresses. Ironic, because both disciplines share a deep conviction that humans, empathy, conversation and context play central roles in their successful practice. And both are devoted to making things better.

The short video excerpt below is from 'ZERO SPACES - a portrait of Ranulph Glanville' (Mavignier, 2015).

Ranulph was an architect, cybernetician and design theorist, and my supervisor.

In this clip, I explain why appropriate, thoughtful design of the EHR interface makes for a richer, deeper conversation with the patient—and better quality care.

Mavignier, D (2015). 'ZERO SPACES - a portrait of Ranulph Glanville'.

Available at: https://vimeo.com/mavignier/zerospaces

Oppenheimer, Robert. 1953. “BBC Reith Lectures: Science and the Common Understanding. Lecture 6 - The Sciences and Man’s Community.” London. http://downloads.bbc.co.uk/rmhttp/radio4/transcripts/1953_reith6.pdf.

Oxman, Neri. 2016. “Age of Entanglement.” Journal of Design and Science, January. https://doi.org/10.21428/7e0583ad.

Powsner, S. M., and E. R. Tufte. 1994. “Graphical Summary of Patient Status.” The Lancet 344 (8919): 386–89.

Rittel, Horst W. J., and Melvin M. Webber. 1973. “Dilemmas in a General Theory of Planning.” Policy Sciences 4 (2): 155–69.

From 'ZERO SPACES - a portrait of Ranulph Glanville' (1m30s)