eTech Insight – Can Quiet/Dark Design in the EHR Reduce Burnout? - Cover

eTech Insight – Can Quiet/Dark Design in the EHR Reduce Burnout?

EHR Design Impacts Clinician Wellness

The current loud/bright cognitive designs of the EHR are a factor driving clinician burnout. The barrage of clinical information available in the EHR requires clinicians to sift through clinical documentation, problem lists, clinical alerts, diagnostic results, and in-basket tests to decipher what information is truly important for providing quality care to the patients. Add text messages, emails, and voice mails to this mix and you have a cornucopia of information that can hide important patient information from the clinicians. A recent article on EHR design is bringing attention to a new approach that has been used in the design of commercial airliners for years—quiet/dark cognitive design for assessing only important information.

Dr. Thomas Tinstman, who is also a pilot, has been pushing airline cognitive design and training for EHR solutions for years, and he has been largely ignored. Even the EHR vendor he worked for ignored his suggestions. Perhaps like the quality-improvement designs of W. Edwards Deming, which were initially ignored, the cognitive principles for EHR design espoused by Dr. Tinstman will finally be adopted.

Can Aviation Flight Deck Design Be Used to Improve EHRs?

As aviation systems became more automated and sophisticated, a new design philosophy emerged for flight deck instrumentation: quiet/darki. Crew-alerting and messaging systems were developed to augment the flight crew’s ability to monitor flight systems. These technological improvements resulted in greater safety, reduced crew workload, and two crew operations on the flight deck.

Think about the correlation between the crew on a flight deck and a clinician using an EHR. What if the clinician was only provided with the data or information that was critical to the quality and outcomes of a patient’s care? What if the clinician didn’t have to search for patient information? What if the CDS systems were tuned specifically to create alerts only for clinician-defined notification events? What if less-important patient events were routed to advanced practice providers and nurses who were using their own version of the quiet/dark design?

Advances in AI and intelligent bots may be able to deliver quiet/dark EHR capabilities, but that will happen only if EHR vendors are willing to spend the research and development funds to take EHRs to this next level of cognitive design advancement.

Make the EHR a Desirable Tool for Patient Care

While quiet/dark designs will not provide relief from documentation creation or the requirements for clinicians (although voice recognition with NLP integration may improve that), it will serve as a key factor in improving the efficiency and usability of the EHR for managing and monitoring patient care. Eliminating alert fatigue that can create patient safety issues and the EHR patient-information searches that find relevant clinical data and outcomes should reduce some of the factors driving clinician burnout. What if using the EHR became a desirable function for the clinicians? This can be accomplished only if the design of the EHR is modified to support and enhance the cognitive functions of the clinicians. Providing too much information is not working; can we deliver the right information at the right time to the right clinicians?

Which EHR Vendor Will Gain First-Mover Advantage for Quiet/Dark Design?

The current enterprise EHR vendors (as represented by Epic, Cerner, Allscripts, and MEDITECH) would be wise to consider implementing quiet/dark design in new versions of their EHRs. While this may not be a short-term deliverable, the advancement of AI and intelligent bots may become catalysts for advancing this design. Any new clinical application should be evaluated for delivering this design.

Success Factors

  1. The advancement of AI that can be effectively integrated into the EHR to accurately assess data relative to significant findings and present it in a timely manner for clinician actions.
  2. The advancement and integration of intelligent bots into the EHR that are designed to monitor and alert clinicians to specific clinical events (e.g., the assessment of sepsis or potential cardiac failure).
  3. The willingness of EHR vendors to incorporate quiet/dark design into their EHRs.


EHRs have become complex and sophisticated environments that capture a plethora of patient data and information. In many cases, a clinician’s ability to extract the pertinent data and information from these environments is not efficient, and that may result in higher clinician burnout levels. The healthcare industry is now at a critical nexus for EHR usability and efficiency. How can next-generation EHRs be designed to support and enhance the cognitive functions of clinicians? Can the cognitive functions of quiet/dark design that was used to improve efficiency and safety and reduce crew workload for airline flight decks also be applied to the EHRs? We believe that this can happen and that the EHR vendors who deliver the data-processing capabilities of quiet/dark design can create much-needed disruptive innovation for the industry.

[i]Human Factors in Aviation; Eduardo Salas and Dan Maurino; Academic Press, January 30, 2010

     Photo cred: Adobe Stock, Wright Studio