Figure 1.Older adult and a healthcare worker wearing respirator masks during a home care visit while the healthcare worker takes notes in a three-ring binder. Source: iStock by Getty Images; Image credit: xavierarnau; License: Licensed by the author. At the University of Waterloo’s Ethical Tech for a Global Future Symposium (October 2025), Dr. Maurita T. Harris urged the audience to examine how values shape the design of technology and what it means to prioritize human factors, justice, and responsibility [1]. Her keynote emphasized that innovation without an ethical foundation often worsens inequities. While her examples focused on healthcare and older adults [1], this issue extends across domains where technology intersects with human vulnerability. We see this in intelligent facial recognition systems, which promise to transcend the subjectivity of human observers, yet hardcode racial biases into the infrastructure of security [2]. Similarly, automated hiring algorithms promise to eliminate human prejudice from recruitment, yet often embed historical exclusions more rigidly than the context-aware reality of manual resume review [3]. This same gap between high-tech promises and lowtech realities is demonstrably visible in the complex, unpredictable environment of home care [4].
Prompted by Dr. Harris’s call to center the margins, my attention turned to a simple, recurring artifact within my research into technology development for complex home care: the binder. A three-ring binder, often found on top of the fridge or the kitchen table, filled with handwritten logs, plastic sleeves, sticky notes, and checklists near care activities such as those in the bathroom [4], [5]. For anyone who has cared for a loved one with complex health needs, this image is familiar (see Figure 1). Paper-based documentation is portable, transparent, and shared among caregivers. It provides a single source of truth for rotating teams of family members, personal support workers, nurses, and visiting physicians. In our study of caregivers of children with special health care needs and older adults, every participant relied on, to varying degrees, paper-based systems because the technologies used by home care agencies were siloed or inaccessible [5], or because digital tools failed to reflect the realities of home care, including complex diagnoses, medication regimens, and daily tasks [6].
The binder is a proven home care coordination technology with long historical roots in the personal health record.
However, while the binder may perform better within the marginal(ized) spaces than more complex technology-based tools, it is by no means a perfect solution. For example, it demands significant cognitive and emotional effort from caregivers. As one caregiver participant expressed to us:
“I’m expected to come in with my binders of information and fill them in on everything… it’s crazy exhausting.” – P04 [6, p. 6]
This exhaustion is the result of a design problem within the home care information management and communication system rather than simply a result of human error [6]. The binder is therefore an essential starting point for design because it reveals the shared access, continuity, and flexible documentation functionalities that caregivers actually need, alongside the labor they are currently required to absorb. The goal of innovation is to recognize and preserve what nondigital, user-created systems like the imperfect binder do well while designing technologies that meaningfully reduce burden and advance communication and coordination, starting from the margins. Otherwise, we simply digitize those burdens into device interaction fatigue that forces caregivers to invent workarounds all over again, and our innovations may only work for some, but not all, or those who need it most. The rest of this commentary develops this claim through a collective-care lens and tests it against “smart” home health tools explored through the prior research I have been involved in.
Binder as Ethical Design: Paper Versus Digital Friction
The binder is a proven home care coordination technology with long historical roots in the personal health record [7]. In design terms, its strength lies in simple features that enable customizability and specific actions [8], such as writing down a medication dose, a description of someone’s mood, or the details of an unexpected accident for personal tracking, as a reminder to follow up on, and for others to read. The binder easily affords these types of flexible and adaptable interactions, but these are qualities that many digital systems fail to adequately support in the home care environment [5], [6].
The binder offers flexibility for health information communication and coordination in complex home care. It accepts quick notes about someone’s day alongside a table of blood pressure readings without forcing caregivers into rigid menus or character limits. It adapts to the complexity of real-world care routines, including the immediate needs of caregivers and how those needs change and fluctuate over time in accordance with the condition of their loved one. It never needs charging or replacement batteries, software updates, a monthly subscription plan, or a password reset. There is no risk for accidentally deleting an entry or an incorrectly autocorrected word gone unnoticed, leading to a disaster like overdosing on a medication.
The binder also offers open access and the easy exchange of health information among caregivers. In complex home care situations, when caregivers change daily or emergencies arise, the binder is available to anyone trusted to enter the home. No two-factor authentication, no connectivity requirements. When one binder fills, another one simply begins. Caregivers are never annoyingly alerted with frequent pop-up messages that the cloud storage is nearing its capacity or full, only to require deleting information to make space or purchasing a costly subscription upgrade. When a clinician or home care agency shares copies of important paperwork, they can be easily added to and organized in the binder. This continuity of health information is critical for safe and effective care.
Conversely, digital tools for home care often introduce friction with their users. Current research identifies that not all caregivers, formal or informal, can access the recorded health information [5], that some of the technologies that they can access do not reflect home care realities of knowledge sharing or record keeping that they need [6], and that health information technology often lacks granular, rolebased permissions [9], effectively locking them out of official conversations for coordinating care. For developed systems, a forgotten username or drained battery can break care continuity. A rural internet outage can halt care coordination. An incompatible device can leave caregivers disconnected. The lowtech binder, however, persists.
This commentary is not an argument against the high-tech promise of digitizing health information in complex home care, but to respect the low-tech solution that often “just works” and use the binder as a starting point for innovation that supports caregivers with the functional aspects where the binder fails, which extend beyond upkeep burdens. The binder works best when care is co-located, where information is “shared” because it sits in the same physical space. But complex home care routinely stretches across distance and shifting schedules, and paper-based tools cannot support real-time, two-way communication and coordination when a caregiver is off-site, a clinician needs an update between visits, or a handoff happens mid-crisis. Despite not having the same type of storage constraints as a digital tool, it can also be difficult to search and synthesize information within a growing binder, especially when the binder becomes the binder’s. Caregivers must manually translate notes and records into the summaries that enable safer decisions, sometimes under stress, and this can also be an exhausting undertaking when onboarding a new caregiver [6]. In principle, the higher-tech tools could help by enabling remote access, confirmations that messages were received, and automated summaries to make up for the limits of the binder.
The binder succeeds because its design aligns with caregivers’ environments rather than abstract or idealistic workflows that digital solutions may try to prescribe. Digital systems must therefore do more than copy data if they seek to preserve the flexibility that home care demands as well as the trust that is built up and maintained among caregivers using low-tech solutions [5], [6], [10]. A nonexhaustive list of features these types of tools should strive to emulate includes accepting unstructured notes as valid and valuable inputs, enabling emergency access without barriers, and functioning offline, as well as across various device platforms. Until the design of digital technologies matches the accessibility and reliability of the paper-based binder system, the binder remains the more ethical coordination tool for communication and continuity in complex home care. Importantly, it also clarifies why ethical design in this domain must move beyond the individual user to the caregiving network as a whole.
Until the design of digital technologies matches the accessibility and reliability of the paperbased binder system, the binder remains the more ethical coordination tool for communication and continuity in complex home care.
Collective Care: Moving Beyond the Individual
If the binder’s primary user is effectively a multidisciplinary team, then ethical design in home care cannot stop at the individual interface. Dr. Harris argued that responsible innovation requires centering the lived experience at the margins, and this is precisely where the binder lives. Achieving this shift in design thinking requires us to expand beyond a model focused on individuals to one grounded in shared care and compassion. Traditional user-centered design isolates a single, sometimes considered “average” user—the patient, clinician, or caregiver—and optimizes their interaction with a device or system [11]. It asks if buttons are easy to press or fonts are easy to read, how efficient it is to use the device, and how pleasant or enjoyable the experience is.
However, complex home care consists of a network of relationships and handoffs among family members, hired caregivers, nurses, and physicians, and the binder makes this network visible. In practice, it acts as a place where rotating caregivers leave notes, update checklists, and maintain a continuous story of what happened last and what needs to happen next. Its user is the caregiving team rather than an individual, making this another reason why it persists.
Therefore, instead of asking how one user enters data, we should ask how information moves across this network. Does the system support trust among caregivers? Does it enable shared awareness of the home care environment? Does it help caregivers keep the older adult or child with medical complexities safe?
Our research suggests that failures and caregiver stress occur when this collective awareness breaks down, such as when communication feels one-way, or families are excluded from the systems used by home care agencies, or because the binder’s co-located visibility cannot extend to off-site caregivers and clinicians [5]. Caregivers want confirmation that messages are received, shared calendars, and checklists that reflect real-world routines [5]. Their priority is relational integrity among the caregiving team. Preferences for interface esthetics come after.
Empathy and Compassion as Fundamental for Ethical Design
When discussing the importance of collective care for ethical technology design, it is prudent to recognize the element of empathy, and in the context of the engineer building those technologies, their professional responsibility to the safety and welfare of society [12]. If engineers treat empathy as a core skill, they can better understand the diverse physical and cognitive needs of users and avoid designing for that imagined average person or home care situation [12]. The home care binder is a useful reminder here because it is not built for an average caregiver or a standardized routine, but continuously reshaped by caregivers to fit changing conditions, shifting roles, and the messy realities of care. Collective care requires empathy as a disciplined design capability.
If engineers treat empathy as a core skill, they can better understand the diverse physical and cognitive needs of users and avoid designing for that imagined average person or home care situation.
When Dr. Harris emphasizes the importance of designing for the margins [1], she does not mean designing for a niche, nor is it the same as handling rare edge cases like in software design and testing. In technology design for complex home care, the margins are where technological systems fail the caregivers, and subsequently their loved ones, but the binder persists because it already accommodates those failure points by allowing for unstructured notes and functioning without passwords or connectivity requirements. Building for the margins is therefore the ultimate test of resilience for any digital technologies designed and deployed for this environment. For example, if a developed system works for caregivers during a crisis without Internet connectivity, it will work easily for most users under most, if not all, conditions.
Especially in the context of home care, the idea of an average user is a deeply flawed concept because it ignores the importance of relationships in making systems resilient to unexpected inputs, changes, or variations, which is key when taking a design approach using a lens of collective care. History shows this across domains such as aircraft cockpit layouts to medical devices [13], where designing for an average person ends up excluding real-world system users. A topical example is the N95 respirator: fit is essential to preventing harmful leakage, yet historical design and testing standards drew heavily on ref-erence-male datasets [14]. Women, who constitute much of the nursing and home care workforce [15], are not simply smaller versions of men, and they fail fit testing at higher rates as a result [16]. When the average becomes the baseline, the system protects some while exposing others, breaking collective care at the point where protection matters most.
Complex home care makes the same lesson unavoidable. Unlike regulated hospital environments with standardized resources and protocols, there is no average caregiver and no average home care environment. When digital systems assume stable routines, reliable connectivity, or a single primary user, they create gaps where safety and health information can leak out, and these are exactly the gaps the binder is there to close. Therefore, when a design excludes or fails to consider the unique characteristics and the needs of real users by focusing on an average user, an ideal case, or a single user type, the entire system becomes fragile and may collapse under real-world use, potentially resulting in abandonment and unethical consequences across user groups.
Building on work that centers empathy in engineering design [12], a collective care lens in design thinking treats caregivers and patients as collaborators in the design process of home care technologies. Grassroots tools such as the binder are positioned as legitimate, context-responsive tools that anchor innovation. Empathy identifies where the work and stress live; compassion is the decision to build systems so caregivers do less of it. In complex home care, that compassion looks like concrete design choices that reduce cognitive and emotional burden by simplifying coordination and documentation and preventing avoidable errors, rather than shifting more work onto caregivers. Validating the binder as foundational to home care technology design is one such step because it acknowledges the stress caused by siloed digital systems and recognizes that the real user is a network of various people working to keep someone safe and healthy. Innovations in this space should support that collective effort, not disrupt it.
Case Studies in Digital Friction: The “Binder Test”
In this commentary, I suggest applying a “Binder Test” which asks a simple question when evaluating a new high-tech concept for home care: compared to the low-tech systems caregivers already rely on, does the new technology preserve (and extend) the core benefits that make care coordination resilient? Reflecting on my home care research [5], [6], these baseline evaluation heuristics should include, nonexhaustively: 1) accessibility for all users; 2) flexibility for unstructured documentation; 3) shared access across users; 4) dependable function under stress (including offline reliability); and 5) transparency and auditability: the ability to see what was recorded, by whom, when, and on what basis, so that caregivers can verify, correct, and develop trust in the record. A new tool may be technically advanced, but if it undermines these factors of the binder by adding barriers, producing untrustworthy outputs, or breaking continuity, it may be socially fragile in real home care settings. Two areas from my research involvement—voice assistants and medication adherence devices—illustrate this gap between engineering intent and lived caregiving experiences [17], [18].
Smart Voice Assistants and the Risks of Artificial Intelligence
For everyday home care coordination, the lowtech comparator is a system of artifacts anchored by the binder: handwritten logs, checklists, quick notes left for the next caregiver, and human handoffs that allow clarification when something is unclear. These systems are imperfect—such as when a human handoff does not occur—but they provide an auditable trail for the team to determine what was done and what needs to be done next. In the case of smart voice assistants, the Binder Test turns most sharply on dependability under stress and transparency/ auditability: when caregivers ask a question or capture/retrieve a note hands-free, the system must be reliably correct (or explicitly uncertain) and leave a record the team can inspect and trust.
When we examined the potential for smart voice assistants as a high-tech augmentation of the binder (before the dawn of ChatGPT), caregivers of older adults and children with complex health conditions perceived it as potentially useful for hands-free and unstctured documentation and information retrieval (e.g., Hey Siri… “Did they take their hydromorph contin today?”) [17]. However, the rise of generative AI and large language models (LLMs; systems that predict words to generate human text) increases risks that could directly violate binder-like reliability, transparency, and trust. For example, hallucinations—confidently incorrect answers (e.g., about drug interactions)–would fail the Binder Test heuristic for dependability under stress, as well as auditability if the system cannot clearly show sources, uncertainty, or a traceable rationale that caregivers can verify in the moment [17]. The binder may be messy at times, but it does not invent facts. Furthermore, if the voice assistant cannot understand the user, it fails to support access and accessibility [17].
A second example is effect mismatch, arising when devices perform synthetic empathy, such as a cheerful medication reminder during a time of grief. This may erode relational trust across the caregiving network, making the technology feel misaligned, unsettling, and even inappropriate with the realities of care [17]. Under a collective care approach, smart voice assistants should therefore prioritize binder-like transparency by clearly admitting limits, avoiding quasi-clinical advice, capturing spoken information into an auditable record, and defaulting to human escalation in emergencies or crisis moments [17].
Smart Medication Adherence and the Metrics of Trust
Medication adherence in home care is often coordinated through low-tech infrastructure like blister packs or pill organizers [18], printed medication lists, routines, and binder-based logs that allow caregivers to verify what was taken and when across shifts [5]. For the smart medication adherence tool, the Binder Test emphasizes accessibility and dependable function across real-world constraints of portability, accessibility, and cost requirements, alongside shared access and auditability so that medication intake events can be verified across shifts rather than trapped in a single device or account.
In a study of a smart multidose blister package prototype for older adults, participants rated system usability as acceptable (75.5), yet the Net Promoter Score (a user satisfaction metric indicating likelihood to recommend) was zero [19], suggesting that a device may be usable without necessarily being desirable. Several reported issues map directly onto applicable Binder Test heuristics: device bulk reduced portability (accessibility), reminders were inconsistent (dependable function), medication retrieval was difficult for users with arthritis (accessibility), and reliance on an SMS-capable phone and plan introduced cost and access barriers (accessibility and dependable function) [19]. These problems also undermine shared coordination and auditability: if reminders, logs, or notifications depend on a single device or user account, the wider care team cannot reliably see, verify, or act on the same record. Under a collective care approach, adherence technologies should preserve the lowtech strengths of portability, clarity, and cross-caregiver verification, which can at least occur in the home, while adding value to caregivers beyond the home without imposing new barriers.
Aligning design with collective care refocuses requirements for development toward safety, accountability, and the real networks that deliver care.
Ultimately, both of these example cases fail the Binder Test in preserving dependable function under stress, shared access across a caregiving team, and transparent, auditable records that can be trusted during handoffs. Aligning design with collective care refocuses requirements for development toward safety, accountability, and the real networks that deliver care.
Dr. Harris called for ethical, globally responsible design that centers human factors at the margins. Designing for a single, idealized user produces fragile systems. In complex home care, ignoring the shared nature of care creates fragility where services fail when a caregiver is ill, when connectivity drops, or when access is blocked. Families absorb the cost through burnout, stress, and the increased risk of error.
The Binder Offers a familiar image from home care, but it is also a durable coordination tool that makes collective care possible, and it provides an ethical baseline for what works under real-world constraints. In that sense, the Binder Test turns that baseline into a rubric that can be used anywhere caregiving relies on handoffs and shared accountability, which are not just human factors of home care, but include all settings where caregiving teams rotate, where information must be legible to nonexperts, and where care continues despite interruptions. In developing ethical technologies for complex caregiving across education, research, and industry, remember to treat the low-tech and caregiver-built tools, such as the binder, as legitimate starting points. Preserve what they do well (e.g., accessibility, flexibility, shared access, offline dependability, and auditable records) and repair what they cannot without creating new burdens. During design and testing, report workflow fit, team communication, and integration with the same rigor as technical performance, and co-design with family and hired caregivers from day one. Audit reliability, transparency, and physical usability early and do not assume “smart” compensates for poor form factor, or for designs that invalidate caregivers’ values and workarounds. Build pricing and access models for low-income and low-connectivity households first. Center lived experience, design from the margins, and embed shared care and compassion in decisions. Technologies built on these commitments will serve the margins and therefore the mainstream. The question is whether we will hold new tools to that baseline.
Author Information
Ryan Tennant is a human-centered researcher. Working at the intersection of cognitive systems engineering, applied psychology, and artificial intelligence, his research focuses on the responsible design and integration of digital technologies into complex, high-stakes healthcare environments. Supported by an NSERC Canada Graduate Scholarship and Waterloo Engineering Excellence Doctoral Fellowship, his doctoral research applied cognitive work analysis and ecological interface design to inform AI system design and develop clinical decision-support interfaces for paediatric sepsis prediction. Tennant has a BASc in biomedical engineering and an MASc and a PhD in systems design engineering from the University of Waterloo, Waterloo, ON, Canada. Email: ryan.tennant@uwaterloo.ca.
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