It is not difficult to envision a better EMR than already exists on the market, because they all suck. And they all suck for the exact same reason: They were designed by software developers, not health care professionals. They should all carry a label–Caution: This product was never intended for actual use by a doctor or nurse in the care of a live patient. This fact is obvious to anyone who is forced to use one of these programs while sitting in front of a patient, as opposed to running a demo of the product in front of a group of naive physicians. Gee, we all think, it looked like it worked when the guy was clicking through all those “uniquely designed, personally templated, specialty specific and easily customized” screens. Which, in case you still haven’t figured it out, weren’t really running the program but were just carefully choreographed prescripted, preloaded, dummy demo’s. You figured that out after you bought it, right?
Step One and Only in designing a real EMR: Make the EMR fit the health care professional, not the other way around. Doctors do not sit in front of fixed monitors with a mouse and keyboard. They sit in front of patients. We reach out and touch the patients occasionally (well, some of us still do, anyway). We make eye contact with the patient and family members, not with a computer screen while we ask questions of the patient over our shoulder. Doctors and nurses do not click radio buttons. We don’t do “drop-downs.” I decide what fields are mandatory, not some hospital IT guy who gets told by the CFO that the hospital reimbursement will go up if we can make the doctors document the reason the patient is in the hospital on every note, every day, every time he tries to type anything into the medical record. The medical record is to serve the health care professional’s goal to care for the patient. Let’s repeat that: The medical record is to serve the health care professional’s goal to care for the patient. It is not, therefore, to be designed to maximize hospital reimbursement, regulatory compliance foibles, or translate efficiently into some midlevel administrator’s Excel spreadsheet program to make his quarterly report easier to format. Because you are screwing up the patient’s quality of care just so you can make it easier to run a report on how screwed up the quality of care has now become. Are you with me here?
The following has been proven by multiple, reproducible, double-blind, multicenter clinical trials published in the best peer-reviewed journals: There has never been a system more efficient in accurately documenting patient care than a doctor or nurse dictating their findings and plans into a hand held recording device that they carry with them, the results of which get accurately transcribed, reviewed, and signed. This is the way we document our office visits with patients. This is the way we document discharge and transfer notes. This is the way we document our operative care. It is not helpful, accurate, or appropriate to replace this with a single check-off box that describes my operation as “Repair hernia, inguinal.” But now we can do even better than a simple dictaphone and transcriptionist. Every nurse, doctor, and health care professional in practice for more than a month falls into certain documentary habits, certain turns of phrase, that he uses over and over again. These can be templated, triggered by certain verbal or tactile cues, then easily augmented and modified on the fly to suit the individual patient experience. Reviewed, proofed, and corrected in real time, then electronically signed, sealed, and delivered. Poof! The technology exists. It has existed for twenty years. It’s just that nobody cares enough about the way we actually do things to design this form of input into the multimillion dollar boondoggle that is your hospital EMR. They need to implement this form of input. Mouse clicks and managed care don’t mix. Are you a seventy-year old primary care physician who has always handwritten his notes in illuminated manuscript grade calligraphy with a gold-nibbed fountain pen? Fine, use your nib on a handwriting recognition tablet running Evernote. We’re not trying to put a man on Mars, here. This isn’t a technology problem. It’s an attitutude problem. And the EMR providers attitude is “Screw it, Jack, just write the code. They have to buy it because the government says so.” I’m sorry, I digress.
Doctors and nurses don’t sit down much. We can’t wait until we find a convenient open work station to write the orders that will save the patient’s life. “I’m a doctor, Jim, not a damn transcriptionist!” Or something like that. Your hospital ER will never have enough computer workstations to allow you to provide timely care to your patient when the patients are lined up in the hallways on a busy Saturday night. I need to do my doctor thing on my handy, personalized tablet that I carry with me whenever I am playing doctor. It contains all my personal professional documenting tidbits. It has wireless access to the hospital medical records database, the laboratory database, the radiology database with images available for my review when the radiologist reading of my patient’s CT scan sounds a little–oh, I don’t know, a little ‘intoxicated’ perhaps–and access to my office server with all my personal patient records. It turns on and trusts that I am me because it recognizes my fingerprint, so I don’t have to keep coming up with a dozen new passwords every ninety days to keep some IT guy happily HIPAA compliant. It even can play me the basketball game that I’m missing while I wait for the nurses to come in to do my emergency case. I can talk to it, and I can write on it, and I can tap on it–I can do things that make my care of the patient easy,and efficient, and better. And I can decide how I want to do that, not the hospital administrator who got taken to that “conference” in Vegas on EMR implementation just before deciding which vendor to sign with. Do I sound bitter? Sorry.
I can write orders on my personal little tablet and they get sent to the hospital order computer thing. No more verbal orders. No more orders appearing in my electronic inbox screaming to be signed when I’m sure I was no where near drunk enough to order that stuff last night. But hell, got to sign it or it’ll just bounce back anyway. If it isn’t on my personal tablet, I didn’t do it. So there. My customized order sets, entered with a finger swoosh. Because I write the same orders for patients over and over again. I don’t want to have to make my own special sauce at every hospital, ambulatory surgery center, clinic, nursing home, homeless shelter, and my office. Then rewrite my personal note templates and order sets every time the IT guy decides to trip over the mainframe plug or do “mandatory system maintenance.” I’ll just keep that stuff with me, thank you. You figure out how to make it easy for me to jack my pad into your system, or I’ll go to a hospital that will.
All of this new electronic, streamlined patient-centric data input is to be automatically, consistently, and reliably entered into my personal database, not just yours, hospital administrator. I need to keep an accurate record of how many gastric resections I performed in the past 10 years and how many of those patients died within 6 months of surgery. I need to be able to easily upload my data to the various Boards, Colleges, and regulatory agencies that demand I prove that I’m a good doctor on a frequent basis. The data automatically and easily transfers to my billing software, not just yours. I’m the one generating the data, I think I should be benefitting from the effort. Harrumph.
I could go on. I’m sure you have lots of even better ideas. It’s a start, at least.