Transitioning to a digital environment requires users to make a shift in thinking, though this may not be evident. To ease transitions, digital system designers try to mimic the look and feel of the real-world objects they are meant to represent. This user interface design concept is called skeuomorphism. Though it is employed with the best intentions, it can bias thinking towards the familiar rather than leading users to recognize the advantages of the paradigm shift. We are used to the concept of the two-dimensionality of paper, and our thinking has evolved to reflect this medium. However, our world is multidimensional, and this can be more accurately reflected in the medium of digital technology. Embracing interconnectedness and depth can allow us to expand our understanding and gain novel insight. We can change the way we think and solve problems. Take the electronic health record (EHR): It looks like a paper chart, but it isn’t. If we can grasp the paradigm shift from paper to digital, we may be able to find new ways of approaching, designing, and utilizing a health record to improve health. We may also find greater satisfaction, perhaps even joy, in our systems. To think beyond physical corollaries and address the paradigm shift for what it is, there are some key concepts that need to be clearly communicated.
The world is not two-dimensional.
Paper is flat. Digital worlds are blocks of information that move and interconnect according to logical algorithms. You cannot dig deeper into a sheet of paper to find more information unless you print it on the back or staple multiple pages together. Electronically, you can drill down, around, and through layered data sets to your heart’s content.
If you want to know more about a patient’s potassium levels, you can click on the value and see the trending of potassium over time. Or you can create links within order sets to guide decision-making. Some links can be created using “If, then” and branching rules. If you order the inhaler, the spacer and option for a respiratory consult may be offered. Mapping common routes of curiosity and interconnectedness to each data point is one of the challenges of good system design. Learning to navigate these maps is the onus of the user.
Paper is like canvas. Digital is like building blocks.
Anything can be written or drawn on a piece of paper and interpreted by a viewer. Sometimes the interpretation is correct, and sometimes it is not. Transcription error makes up a significant portion of errors in healthcare.
In an electronic system, information exists in movable blocks. These blocks ensure clear communication. Defining said blocks is done when building the system. Moving from a free-form world to one with defined blocks is like trading in a paintbrush for a set of Lego blocks. You can craft amazing work out of blocks, but no matter what you do, it will not look like a painting. You will need to get to know your blocks and how to put them together.
For example, a building block is required for each medication in the pharmacy. The block points to the pill. The pill is then coded and can be scanned on administration. This creates closed-loop medication administration. The same medication can come in different concentrations or preparations. We are used to writing “PO/IM/IV,” indicating that a medication can be delivered via different routes. However, in electronic systems, there would need to be separate orders to point to the proper preparation.
Information moves differently.
To send orders in different directions using paper, you make copies and move (or fax) the paper to different locations. People and processes determine the direction. Electronically, separate blocks of information can follow different pre-designated pathways. To change the direction of the path, new information must be provided to the system.
For example, in the emergency department, a medication order goes to the nurse who pulls the medication from local stock. However, when a patient is admitted, the medication orders go to pharmacy. The pharmacist verifies the orders and sends the appropriate stock to the floor for the nurse to administer. The workflow may not only be dependent upon location but on the context of care delivery. Determining when an order needs to follow a new workflow, and who designates the moment of change, is one of the challenges that needs to be solved in an electronic system build. Perhaps the solution is possible in the system without user intervention; however, a consistent process is required. As we become more skilled at creating consistent processes, there are more opportunities for system improvement and increased automation.
You cannot turn the page.
Paper pages can be left behind, turned over, and generally forgotten about when no longer relevant (and sometimes even when they still are). On the other hand, electronic information must be cleared from the system either automatically or with intention.
When a nurse carries out an order, they may need to manually remove it from the current orders screen, otherwise, it could trigger others to perform the function. Likewise, if a physician never manages active orders, they may create redundant orders or, worse, duplicate an action that could lead to harm. It is important to think through phases of care and transitions of care to ensure that orders stop or continue appropriately. Current order pages can become messy if not regularly cleaned.
Discrete data unlocks analytics in medicine.
On paper, information gathering requires people to extract data manually. This is time-consuming and costly. After the initial investment in an electronic system, the computer can find the relevant data points. This ability to search data unlocks a world of potential for research and quality improvement. Currently, this can only be realized with discrete data entry. Knowing when to collect discrete data versus free text information is one of the challenges in building a new system. The solution must enable data analytics without diminishing the story or taking more time for the end users.
There are common myths that derail efforts to adopt discrete data entry. One is that current models of natural language processing (NLP) for clinical purposes (such as pulling data out of free text) pass physicians’ high standards for trustworthiness. Getting a diagnosis wrong via NLP error has larger repercussions than your home AI misinterpreting your alarm settings. Building NLP algorithms that decrease our discrete data-collecting workload in medicine is still a work in progress, even with ChatGPT.
Changing a paradigm means that you think and act differently moving forward.
Once in a digital environment, any clinical change you make will need to be reflected in the electronic system. This will require planning ahead and securing the appropriate resources to implement the changes. For example, if you decide to start a new service, you will need to consider how the new users will find their patients and conveniently order and document on them. If you have not done this work prior to hiring, you will have expensive resources sitting on the bench. Additionally, the rate of change in our systems is outpacing our historical support systems. It does not take a lot of support to manage pen and paper, but it does to help people learn and grow in rapidly changing electronic systems. Without strong trainers in place, it’s possible to lose pace with change, creating an environment ripe for burnout. A successful transition to digital means that automation decreases the need for people to physically move information, but increases the need for training, support, and information technology staff to keep systems functioning and improving.
Understanding the five concepts of the mental paradigm shift needed for digital transformation will make using an electronic system more intuitive and improve user satisfaction. It will lay the foundation for further evolution of the system/human interaction. Foundational to this evolution is each of us embracing change, committing to lifelong learning, and applying our knowledge of our new paradigm to utilizing and molding our digital system. Organizations and governments can facilitate by investing in the proper supports to manifest our transformation from a two-dimensional linear transactional world to a multidimensional interconnected web of understanding and interaction.