The digital-clinical disconnect
Why the EHR interface struggles to connect with clinician users in a way that paper never does
Dave Pao
2 min read
November 2023
'... the medical profession actively, viscerally, volubly hate their computers.’
- Atul Gawande (2018)
In her book, How Doctors Think, anthropologist Kathryn Montgomery (2005) reminds us that, contrary to popular belief, doctors are not scientists. I say 'reminds us' because 'the art of medicine' is not a new term—it has been a well-recognised facet of the profession for centuries.
Rather than a science, Montgomery's observations point towards a practice through which clinicians interpret science. This interpretation, within a framework of clinical knowledge, lies at the heart of their practice and is known as clinical reasoning.
To support clinical reasoning the clinician needs—arguably above all else—a suitable tool with which to explore patient data landscapes. The medical record is that bedrock tool which clinicians use to build, and hold in tension, clinical knowledge through a formalised approach to storytelling that for over a century has come to define their professional practice (Hutchison, 1897).
Whilst the defining characteristic of paper records is that they are created (using pen and paper) by clinicians for their own use, the defining challenge of the EHR interface is that they are built by people who are not clinicians. The consequence of this is profoundly negative: the EHR is no longer anchored to a framework of clinical theory. It is no longer artisanal.
This disconnect between the EHR interface and clinician user is a seam that runs heavy and dark through observations of EHR user experience. It is expressed repeatedly in books, institutional reviews and journals; and vociferously in coffee rooms, blogs and on social media.
Perhaps the single most evocative—and informative—social media output has been from Dr Zubin Damania, who goes by the YouTube moniker of ZDogg. His parody music video, ‘EMR State of Mind’ (2015), encapsulates the thoughts and feelings of the hundreds of thousands of clinicians who use EHR every day. It is well worth a watch (with headphones, ideally).
The first verse lays bare the burnout and even the physical pain. And the pain points of poor interoperability, errors in clinical language, bloated records, loss of patient narrative and a shift in focus from patient to the computer screen: 'Notes used to be our story, narrative, but yo, Replaced with copy-paste, now a bloated ransom note.'
The second verse mocks the futile persistence of paper in a supposedly digital ecosystem and laments the absence of innovation in healthcare technology, contrasting it with digital progress in the wider world: 'Innovation all around, but it ain’t in healthcare, Internet and apps for you, but we get ancient software.'
The final verse is a plea to preserve what is at the heart medicine—the caring and the teamwork—and mitigate the threat the EHR poses to the principles that guide clinicians in their practice: 'Tech should bind us, connect not blind us, to the reason why we care.'
The choruses capture the sense of resignation clinicians feel: ‘EHR, just a glorified billing platform, With some patient stuff tacked on.'
The song is a call to arms, urging clinicians to voice their frustrations and demand a new, more intuitive and appropriate EHR that authentically serves their professional practice needs.
Gawande, A. (2018). Why doctors hate their computers. New Yorker, 12. Available at: https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers
Hutchison, R. (1897). Clinical Methods. Philadelphia, PA, USA: Lea Bros.
Montgomery, K. (2005). How doctors think: clinical judgment and the practice of medicine. Oxford, UK: Oxford University Press.
ZDogg. (2015). EHR state of mind: An Electronic Medical Records parody. [Online]. Available at: https://www.youtube.com/watch?v=xB_tSFJsjsw
