Imagine a world where medical records are never lost, doctors and hospitals are more efficient, and no matter where you are, your physician can access your notes at the click of a button. That’s the attractive promise of the electronic medical record (EMR).
Hospitals across the western world are buying into EMR systems. The prestigious Great Ormond Street Hospital in London has just embarked on a £50 million project to digitalise its paper records. Walk through the hospital corridors and you will spot banners with slogans such as ‘Future Proof’ and ‘We can do this,’ designed to assure doctors of the benefits of the new technology.
In New York City, Mount Sinai also began implementing an EMR system as early as 2005 in a bid to go paper-free and to ensure many of the hospitals systems are connected through one technology provider. Despite this, in 2019, the technology is yet to be fully applied.
The hospital says this is to minimise disruption; however, mounting evidence suggests the most popular EMR systems are not fit for purpose.
With one recent report revealing 95% of clinicians associate EMR usability with burnout, it’s clear the technology is not living up to the hype. A lack of user-friendly interfaces coupled with little capability for interoperability is frustrating physicians and impacting their relationships with patients.
One doctor is trying to change this. Dr Dave Pao is both a clinician and a design PhD candidate at the Royal College of Art, London. He has more than 20 years’ experience working as a doctor in sexual health and HIV and he has experienced the negative impact of EMRs first hand. Now, he is championing the design of EMR through visual provotyping, which aims to solve some of the clinician’s biggest challenges when using the technology in a clinical setting.
“I realised how much the EMR was affecting my performance as a doctor,” he explains. “Patients would get up to leave and I would still have two minutes of clinical coding to enter before my next appointment. As they were walking out the door, I would be typing while saying goodbye. It’s damaging for the doctor -patient relationship.”
An incomplete history
Often, EMR systems will ask the doctor to click through multiple screens and check numerous boxes or dropdowns when entering data. But data entry is the least of their problems – the ability to access data in a meaningful, intuitive way is woefully difficult and often the data is presented in its raw form.
There is a lack of design knowledge around how to support the clinician in their exploration of patient data, otherwise known as clinical reasoning. This is frustrating healthcare professionals, who are already limited to a 10-minute appointment and cannot afford to waste time navigating troublesome systems, while tending to the patient.
As part of his research, Dave surveyed clinicians working in sexual health and HIV across England. He found the number one source of dissatisfaction was this failure to give an overview of the patient’s history. Knowing a patient’s previous history is the key to good clinical practice because it puts everything into context. This leads to the second criticism – a lack of eye contact with the patient due to the amount of time spent looking at the computer screen.
“Using our current EMR system, which has 70% market share in the speciality, I cannot succinctly view the patient history on one screen. Instead, I have to double-click each individual visit. It’s untenable for me to double-click through each consultation, because, in addition to the time taken to access the notes, each episode takes a minute to read,” he explains.
For some appointments, this can be irritating. But for others, it can lead to serious medical errors or psychologically impact the patient and result in a loss of trust in the physician.
The clinician then opens a new template to enter data for the current consultation which takes them through a predetermined set of questions, and often they do so without full knowledge of the patient’s previous history.
“Last year I was sitting in front of a girl, she was about 21, a student at the university. She had visited us 10 times over the past four years and seven visits ago she had been sexually assaulted,” says Dave.
“One of the questions was ‘have you been a victim of sexual assault?’ She just looked at me and burst into tears and said: ‘well, two years ago I was raped, and I was sitting in this chair talking to a doctor who was sitting in your chair.’ Then, they always do the same thing, they look at the screen and say: ‘is it not in there somewhere?’ And, of course it is, but it’s hidden deep down inside the system. You’re always on the back foot because you know the patient knows more about their history than you do – that’s a terrible feeling.”
A science and an art
According to Dave, EMRs are failing because the designers view the clinical consultation as a process with distinct tasks, rather than an unfolding, unpredictable conversation.
“I’d really like EMR designers to understand that from the second a patient walks through the door and sits down, it is furthest away from a fixed, linear 10-minutes than you can ever imagine.”
“There is nothing steady and static about the clinical consultation. It’s not primarily about getting tasks done. It’s first about letting the data unfold and looking at the patterns. That’s one thing EMR designers do not consider, they try to nail down a checklist and I think consultations are the opposite of that,” he says.
This is in part due to a failure to understand the ‘art and science’ of clinical practice – the scientific and human sides of medicine.
The clinical consultation is both a data analysis exercise and an exploration of the patient’s perspective. However, a lack of collaboration between user experience designers and healthcare professionals means the system does not facilitate clinical reasoning.
“Right now, an EMR is a glorified database. All you can do is type. You can’t easily annotate or summarise. The major advantage of digital over paper is that data in does not have to be the same as data out. Across 10 visits, 10 different doctors or nurses could have entered loads of data, but what I need, when I’m retrieving the information, is a system that helps distil this information into clinically -relevant patterns.”
“I believe that healthcare is one of those weird disciplines which designers think is really complicated and so they are scared to introduce risk. But actually, if they had sat down with any doctor or nurse, they would see that our work is not really a science, it’s a practice that uses science,” he explains.
“Most designers would look at this practice – the art and science of medicine – and they wouldn’t know where to start, so they don’t want to even try. They don’t want to get anything wrong. They want to make an impact on EMR interfaces, they really do, they just don’t have access to the clinical expertise. Whereas If you look at patient-facing apps, where the designer naturally understands the patient viewpoint, some of them have nailed it.”
Frustrated by the systems used widely across the UK, Dave is combining his experience as a physician with his PhD in Innovation Design Engineering to develop an innovative EMR interface that uses data visualisation to paint a concise picture of the patient.
Central to his approach is dual process theory, which hypothesises that cognitive processes are divided into two categories. First, we think quickly, recognising patterns and using our intuition. Then, we think slowly, using our logic and cognition to reason with the data.
Current EMR systems do not to support the fast and slow thinking phases, which are dependent on understanding trends and patterns. Instead they demand slow phase thinking throughout, which causes fatigue.
“The bottom line is that physicians need data that we can navigate and explore. At the moment the EMR is not geared up for clinical reasoning and cognition, it’s just geared up to store data,” he reveals.
Dave’s provotype takes the data and visualises it, illustrating patterns over time.
As a result, the clinician can see the patient’s entire history, their test results and the basic information contained in the EMR on one screen. This is invaluable for ensuring appointments are efficient and effective for both the patient and the doctor.
A provotype is a provocative prototype, introduced in the design development process to cause a reaction – to provoke and engage people to imagine possible futures. This is different from a prototype, which tends to be closer to the representation of a design idea.
“It’s not the provotype itself that is important, but the visual provotyping approach. Central to the process of design is the drawing, sketch, or doodle, which can then be collaboratively modified or redrawn – a visual conversation. This gives computer programmers a tangible insight into the way clinicians think, in a way that questionnaires, interviews or essays never could,” Dave says.
“The data mirrors clinical reality, it’s anchored to clinical practice. All the information is in order for when the patient walks through the door – their history, the nature of the examination and the tests they have done. There is a pattern there that all clinicians recognise.
“That data ripples out, not just between me and the patient, it ripples out to the organisation, out to Public Health England and NHS England, out to the researchers. To have reliable, verifiable, clinical data collected at the point of care is really valuable.”
Changing the rules of the game
Dave’s goal is to understand what clinicians need from their EMR to support clinical reasoning. As a result, he is consulting other clinicians on the ground to find the root cause of their challenges. Aside from surveying all UK doctors working in sexual health and HIV, he is also taking his provotype to workshops to test drive it and iteratively improve the technology.
He has used this information to take his research one step further, developing a series of usability principles that are specific to healthcare. These rules guide designers, helping them to build digital technology for doctors that is fit for purpose and meets their wide range of needs. Importantly, the principles ensure healthcare professionals can recognise trends and liberates them to draw conclusions that benefit the patient.
“They are really basic things – it gives me a good overview of the patient history without clicking too much, salient social and clinical data is always visible at a high level, I do not have to jump out of different screens, previous history pulls through so I don’t always have to ask about the patient history,” he reveals.
Physicians of the future
The future looks bright for Dave. His provotype has been a hit with healthcare professionals. During his initial survey, 60% of sexual health and HIV doctors in England described EMRs as having unfavourable usability. After he conducted the same survey about his provotype, this number dropped to 5%, and he is still iterating his design based on the comments of those few healthcare professionals with criticisms.
However, well-designed EMRs are just the first step in developing a more patientcentred clinical appointment, as Dave explains: “The old-fashioned patient model is one of patronage – the patient thinks there is something wrong with them, they go to the doctor and the doctor tells them what to do. In years to come the patient and the doctor will meet, or the artificial intelligence bot and the patient will meet, and you will be in this space where the doctor will guide the patient through a shared interface, rather than telling them what to do.”
“It’s an exciting time to be working in healthcare and with digital health there is so much potential to really make a difference to patients’ lives.”
By Natasha Cowan