How big is your baby? Doctors use design to uncover insights in children’s health


The pediatric growth chart is a time-tested tool of the trade for pediatricians around the world. But some doctors say that as those charts have been digitized for inclusion in electronic health systems (EHR), they often fail to give clinicians a quick and accurate picture of how well a child is growing.

According to recent studies, pediatricians aren’t the only ones who find that electronic health records include design flaws that make it difficult to find data and complete important tasks.

The SMART Platforms Project, led by doctors at Harvard Medical School and Boston Children’s Hospital, is building a set of apps meant to optimize EHRs for doctors. Their most recent project combines medical expertise with design thinking to give clinicians an interactive growth chart that quickly highlights the most important information.

“Central to the practice of pediatrics – both in prevention and diagnosis – is this growth curve,” said Isaac Kohane, a pediatric endocrinologist and principal investigator of SMART (which stands for (Substitutable Medical Applications & Reusable Technology). “And, sadly, it’s the most neglected portion of the record in EHR because a) it’s different and doesn’t look like most of the data and b) pediatrics is a relatively small market compared to adult medicine.”

How can doctors’ intuition inform design?

SMART growth 2 SMART has already built a handful of apps, but to recreate the pediatric growth chart, the program turned to a design firm for the first time. Over several months, designers from design consultancy Fjord worked with a panel of medical experts, including a pediatric cardiologist, statisticians and pediatric endocrinologist.

At first, the designers’ role was absorbing as much as they could and, at times, that meant totally recalibrating their perspectives, said Charlie Gower, the lead designer on the project. “We’d find ourselves saying ‘that sounds ridiculous,’” he said. “Initially, it’s quite different, the things they want and the things they need.”

But, over time, his team came to understand the doctors’ point of view, he added.

“Doctors tend to do an awful lot from their gut – they’ve sucked in knowledge over a great deal of time and this knowledge informs what they do,” Gower said, “They have ways that they like to do things and ways of doing things that they rely on.”

SMART growth 3The result of the partnership is an interactive tool that gives clinicians an easy way to view graphs showing a child’s entire growth picture, including length, weight, head circumference or body mass index, while letting them choose the graphs and comparisons that are most appropriate for that child. For example, while most clinicians might only look at a standard Centers for Disease Control chart, SMART’s tool lets them choose from other charts from the World Health Organization or those for children with Downs Syndrome.  It also lets them quickly plot development measurements against several charts at once.

All of that may sound fairly simple, but Dr. Kohane emphasized that children quickly establish a pattern of growth, and deviations from that pattern can provide early signals of obesity, thyroid disorders, Celiac disease and other conditions.  While standard EHR tools may make it harder for doctors to pick up on those aberrations, SMART’s app actually detects anomalies and notifies the doctor to take a deeper look.  It also spots data entry errors and provides parents with a less technical view of their child’s growth — another helpful feature given the confusion and concern growth charts can often create.

Building an app ecosystem for electronic health systems

Beyond the specific use of the tool, this partnership between doctors and designers highlights a growing trend. As doctors bring more of their devices to work and as more direct-to-patient health and wellness tools emerge, design is becoming an increasingly important consideration in building health services, said Gower.

And, added Dr. Kohane, the hope is that apps like this can motivate a larger community of developers. Recognizing that the world of electronic health records is dominated by giant vendors that can take time to innovate to meet clinicians’ needs, SMART was created with funding from the Office of the National Coordinator for Health Information Technology of to support an ecosystem of apps that can be layered on top of existing EHRs.  Once a vendor or hospital IT department implements a software container, Dr. Kohane said, a hospital can install a SMART app for free.

When it first launched, the program focused more on the technical aspects of adding its apps to an EHR system, but now its emphasis is building apps that can show its potential. “[We want to] make apps that really inspire people to work forward much in the way that many of the early iPhone apps were inspiring to others,” Dr. Kohane said.


Heather Haugen

I believe that the next step toward making meaningful use actually meaningful is to ensure that caregivers are using technology consistently and accurately to achieve quality outcomes and improve patient care. As a parent and an EMR professional at The Breakaway Group, I think it’s great that The SMART Platforms Project recognizes this, and is encouraging collaboration between designers and caregivers to better optimize EHR use. When organizations struggle with adoption of new technology, they often blame the user for resisting change. While it is true that user resistance can slow adoption, the user attitude is simply a barometer for how prepared the organization is for change and how they have chosen to educate caregivers. Consider the value of training caregivers to use EMRs through role-based simulators. Simulation provides an opportunity to practice in a real-life environment without real-life risks and consequences. Caregivers learn in their actual EMR application, which is critically important for learning workflow and gaining new knowledge about their system. They only learn tasks that are applicable to their role. For example, physicians learn to enter orders and write prescriptions, but don’t have to sit through training or functionality they will never use. It shortens the learning curve by ensuring caregivers are proficient in the use of the system, ultimately feeling confident enough with the technology to adopt and use it to provide care.

Andy Spooner

This app would be handy if you had an EHR whose developers were at once savvy enough to be able to manage an app-friendly architecture, but not savvy enough to program a decent growth chart. This might be hard niche to find.

Paul Manner

At first, the designers’ role was absorbing as much as they could and, at times, that meant totally recalibrating their perspectives, said Charlie Gower, the lead designer on the project….But, over time, his team came to understand the doctors’ point of view, he added.
…Gower said, “They have ways that they like to do things and ways of doing things that they rely on.”

Um, yeah. Glad you noticed, Chuck. Maybe you could pass this on to the designers of other EMRs – some of us have been at this doctoring thing for a while, and we know what works and what doesn’t. So if you’re the 29 year old software stud, try learning what we do first, before you try to “improve” things. Thanks.

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