The user interface for EHRs should be uniform

The first thing I noticed when I walked into the physician’s office were the tall cabinets filled with manila folders, tabbed with names and organized alphabetically. There were three of these cabinets, taking up the entire length of the back wall, filled with hundreds upon hundreds of patients’ records.

“I see you still have paper records. Do you plan on implementing an EHR anytime soon?” I inquired.

The doctor paused for a moment and said, “No, not really.” Surprised, I inquired why.

“Well, there are a couple of things holding me back. The first is cost. There’s an initial set-up fee, a maintenance fee, a technical support fee, a hardware and software fee. The fees just keep piling up and it isn’t sustainable for a small practice like mine. Second is compatibility. The local hospital here uses Epic, but we use an Allscripts based system for logging in patients. It’s not a full-fledged EHR, but the point is that it isn’t the same as Epic. There’s a lot of training involved in using all these programs, which means you need time to learn – time I don’t have.”

I shadowed him for the rest of the day, watching as he spent a good five minutes writing down pertinent information after every patient encounter. By the end of the day, I realized in the four hours that I had shadowed him, nearly an entire hour had been dedicated to writing. Wouldn’t an EHR system make his workflow a lot smoother?

Today, we have a plethora of new EHR systems – Allscripts, Epic, GE, ADP, and MediTouch are just a few of the many brands available. As a relatively new market opportunity, there are bound to be hundreds of offerings from all sorts of companies, big and small. Navigating this sea would be difficult for any physician pressed for time. A recent study on EHR adoption in New York, the state with the most incentives for EHR implementation, showed that even hospitals had adoption rates no higher than 25%. If the big budget hospitals can’t adopt it, why would independent physicians?

What’s more interesting, however, is the incompatibility between the market economics of emerging EHRs and the realities of medicine. Medicine, at its core, is about sharing helpful information through uniform and easily accessible scientific channels. Free market capitalism is essentially a competition for dollars that leads to product diversification and stratification over a long period of time. With the introduction of 32 million newly insured patients with the Affordable Care Act of 2010, the need for streamlined patient information is greater than ever before. If EHRs are going to flourish in the rapidly expanding world of medicine, we’re going to have to quickly implement two very anti-capitalistic initiatives: standardization and consolidation. I’ll explain momentarily.

Medical history is a mobile platform that moves with the patient. Considering the extent to which patients see various specialists, physicians need to employ patient-centric records that are easily transferred from one physician to the next in any clinical setting. This means a patient’s information from a primary care physician’s office should seamlessly integrate with whichever hospital or clinic that patient visits.

The Health Information Technology for Economic and Clinical Health Act of 2009 already attempts to enact this seamless transition by requiring EHR companies to build up software on standardized data formats. Congress rewards physicians who employ such EHRs with financial incentives, calling their decision an example of “meaningful” use of medical technology.

While this level of standardization is progressive, I would suggest we take it further – the user interface for EHRs should be uniform in geographic areas, if not nationally. It makes no sense that local clinics use Allscripts while the nearby hospital uses Epic, especially when physicians practice in both places. Asking physicians to orient themselves to a new user-interface every time they visit the hospital or clinic would be a waste of time and money. Even if the underlying data transitioned smoothly, the physician can’t access it as easily as on the EHR he or she was trained with. The usefulness of that patient information becomes moot.

What makes more sense is employing a uniform EHR throughout a geographic area such as a large city or county. As you expand the geographic boundary requiring a uniform EHR within, physicians practicing in that area will have an easier time consulting at hospitals and clinical local to them. No time will be wasted learning new program interfaces, which translates into more time with patients.

Capitalists would be eager to point out that as the EHR market is allowed to develop independently, a dominant EHR platform will emerge and the entire idea of a geographic EHR will be useless. While that’s true, it would take an exceedingly long time for any one EHR to jump to prominence. With newly insured patients flooding physicians’ offices, rules that can be quickly and easily implemented have to be put into play. A regional EHR is one such rule. If, in ten years, the inevitable dominant EHR develops, then we can reconsider our options.

This is where the concept of consolidation gains importance as well. Currently, EHR companies independently vie for individual physician choice, but, given the amount of EHRs, inadvertently make physicians’ choices difficult. The cost of having an incompatible EHR with local medical establishments can outweigh the benefit of having an EHR in the first place.

Regional EHRs will pave the way for a new business model that will likely be more successful than current ones. In this new model, companies can propose enterprise-class EHR software for a geographic area, which will directly lead to system-wide savings through regional consolidation. Local physicians will pay lighter fees into a pool for regional EHR hardware, software, maintenance, and technical support instead of taking on larger fees for a private EHR system. EHR companies benefit by having steady and stable micro-market dominance. When it comes to EHRs, value stems from uniformity.

Of course, nothing is simple when it comes to healthcare in America. HMOs, PPOs, and other insurance schemes may restrict patient mobility. For example, Kaiser Permanente, one of the nation’s largest HMOs, has their own EHR called KP HealthConnect. It allows for all Kaiser Permanente hospitals and physicians to access any Kaiser Permanente patient’s records. Any patient outside of Kaiser’s HMO policy may not be in the system. Having an EHR tied to an insurance policy makes it difficult to supply healthcare to patients who enter the emergency department without Kaiser coverage. This not only complicates the physician’s job, but may put the patient at risk. Furthermore, any single geographic area is likely to have multiple hospitals that accept a number of insurance policies. Restricting a hospital to a private EHR would hinder its ability to properly serve the public in this regard.

Healthcare is radically changing in the 21st century. We have more patients, fewer physicians, and less time for them to interact. If we want EHRs to have a substantive impact on healthcare, they need to be regionally standardized and consolidated. Only then can we be sure that EHRs will increase physician efficiency and efficacy while improving patient mobility.

Roheet Kakaday is a premed who blogs at The Biopsy and can be reached on Twitter @TheBiopsy.

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  • windingmywatch

    Mr. Kakaday … sounds like you want to pick winners w/out benefit of the market making the choice.  With that perspective you’d be comfortable picking one built by Solindra. 

    You failed to mention a couple of detractors … the PCPs that have to generate the primary care level patient data don’t benefit one iota from generating this data and in fact having to capture and record data determined by Mother ONC as important in format it requires the machines to capture costs the PCP in patient throughput.   If you reduce daily patient throughput not only is the practice not making the revenues it needs to … fewer patients nationally will get care.  

    So … suggest you dedicate yourself to your premed studies … and postulate on things you might be better equipped to address with experience.  This topic is apparently not one of them.

  • bojimbo26

    In the UK , we were going to EHR for use country wide . Because the power that be couldn’t decide on software etc , they scrapped the system on which the taxpayer had to pay £32Bn .

    • windingmywatch

      Lots different in the UK than U.S. though ..

      In UK for the primary care sector there are only about half a dozen EMRs with EMIS owning nearly 2/3 of the market.  Interoperability in UK was market driven when NHS drove the requirement for out of hours services spawned alliances between PCPs and out of hours providers all needing to be able to read patient data and make inputs for the contracted PCP. 

      You are right that EMR unity across the NHS secondary care system has  been a mess which is strange since all NHS facilities operate the same … just like the U.S. VA facilities. 

      In the U.S. there are hundreds of EMR providers for combination of PCPs, hospitals, EDs, and specialties.  There is few orientation toward a common front end because commonality makes you more susceptible to being absorbed and loss of market presence. 

      Hence, there is no market reason for commonality and when the government intitutes standardization of the front end for the buyer’s benefit then that will be the ceiling of what the developers build and will prevent innovation. 

      When the goverment picks winners (as they tried to do in the UK secondary system and in the U.S. as it has done in the automotive and solar energy markets) … citizens and businesses lose.

      • http://pulse.yahoo.com/_GXO5UT3MGTPBRYKXHHFG6NCRO4 S

        WMW: Are you a doctor?  You arguments make little medical sense.  
        The problem with your argument is that there are areas where standardization is critical to function. Anybody in medicine knows how it is woefully lacking in our field from an EMR standpoint. You argue from a “business” standpoint that “There is few orientation toward a common front end because commonality makes you more susceptible to being absorbed and loss of market presence” . That may be true, but from a “medicine” standpoint it results in many different systems that decreases efficiency, makes records difficult to near impossible to obtain, and is frankly just bad for the doctor and patient. You may make the ultracapitalistic argument that when winneres are “picked” that when the government and businesses lose. My counter-argument is there are fields where standardization outweigh loss of efficiency by “picking a winner”.For instance, following your argument we should NOT have one national army but 50 state militias. I don’t think anybody with any introspection would make that argument. Our army functions well as any adversary has found out the hard way. Standardization is critical to battlefield function. It took many years of standardization to turn NATO from many national entities to one (fairly) cohesive unit. There is a reason why all of our state national guard’s are ultimately standarized to serve within US military. I would argue the lack of EMR standardization in the USA has ultimately hurt patient care and it all comes down to the software companies paying off congress with bribes (campaign donations) rather than listen to those of us who actually working in the field.  I have used the VA system and other systems such as EPIC. Frankly, I had a better handle on the VA system in one month than after using an EPIC product for multiple years. EPIC is a user hostile frankly lousy product that was clearly had  little doctor user input and this is touted as one of the ”best’ products…..EMR is a mess right now ask any health professional, and when it comes down to it we and the patients are the end users. Listen to us.  

  • Aaron Johnston

    I’ve yet to meet the EHR that actually saves time or improves workflow, particularly for primary care physicians.
    The EHR will finally be accepted when the interface and input is as customizable as every other computer program, when the learning curve is as simple as MS Office and when the data is stored in non-propriatary formats, easily transferable and exportable.
    Dr. J.

  • http://www.facebook.com/people/Matthieu-Blit/100003700671931 Matthieu Blit

    “Medicine, at its core, is about sharing helpful information through
    uniform and easily accessible scientific channels. Free market
    capitalism is essentially a competition for dollars that leads to
    product diversification and stratification over a long period of time.” >> maybe the problem lies in the contradiction between these two areas.

  • LBENT

    We have had EHRs sinc e1997 in our office.  They are time consuming, costly and interfere with direct face to face patient care.  They are useful when you need to go back and look at what was done. 

    There is too much hype about how EHRs are going to help improve healthcare.  I am very good at typing and talking to patients but still there is just too much information that is required to collect and review which has no meaningful use for my taking care of that patient.  My specialty is pediatric ENT and I am sure it is much, much worse for primary care specialists.

    Government regulation and the meaningful use of the EMR is misguided at best and harmful at worse.   Collecting all that information does no one (except attnys) any good.  And I like my EHR and EHR company, but whent he system is down (due to the “network” provider or loss of power), we cannot care for patients. 

    No panacea. 

  • nsmdphd108

    Interesting idea, however the biggest issue that I have seen in practice is that despite having an emr hospital and clinic providers still get bogged down by having to get records from “outside hospitals” via fax/paper. As a medical student, I’m usually the person on the team finding these records which are crucial in many situations as we are attempting to avoid replicating procedures and avoid giving unnecessary treatments (there are definitely such things – we know that contracting group B strep from mothers can cause life-threatening infections in infants, so if you have a lady who didn’t get prenatal care at your hospital and is giving birth imminently, if you have access to her prenatal labs you can know whether or not it’s necessary to give penicillin to her because you know her group B strep status – additionally most hospitals’ test for group B strep is a culture, which takes >24hours for results.  Not giving penicillin to a lady who doesn’t need it may not save the hospital much money in the short run but it will decrease antibiotic resistance over time by not giving unnecessary antibiotics – and it’s a simple example).

    In my experience this year as a third year student I’ve learned the basics of at least 4 separate EMRs while on various sites and while I don’t have nearly as many responsibilities as a resident or an attending, I found it didn’t take that much out of my life. The attendings that have problems with EMRs are usually older and less computer savvy. Once the generation who grew up with computers is functioning in the attending role, the “it takes too much time to learn an EMR” argument will be moot. However, the burdensome process of getting records between hospitals and practices that do not share systems will be unchanged unless we do something. I’m surprised the emr companies haven’t figured out there is a would-be market for applications that bridge different EMRs. What would serve us well would be to have requirements for software systems that link different EMRs set by law (and would create another market for the staunch capitalists out there) with physician and provider input such that the information we all need to take care of patients is easily available via a secure internet connection.

  • ellendastork

    Not to be rude, but there are also many studies that point to patients feeling that EHRs have led to lack of personal contact between physicians and their patients. Perhaps, this premed student needs to learn about taking care of patients first. One problem among physicians is that we don’t have the time to learn new systems, and end up being led by business people who have little knowledge of the day-to-day activities, stresses, etc. that physicians encounter. Although Mr. Kakaday has some interesting ideas, who is he to tell a very experienced physician who is being kind enough to mentor him how to run his practice? Get back to us in 10 years if you happen to have an MD behind your name.

  • http://twitter.com/TheBiopsy Roheet Kakaday

    Hi readers, 

     

    Thanks for the
    replies! I appreciate you taking the time to read and comment. I just wanted to
    address a few concerns readers brought up in your responses. 

     

    1. It’s true!
    Right now EHRs do get in the way of face-to-face patient interactions that are
    so crucial in doctor-patient relationships. That, however, I believe is a
    design flaw and not so much a problem with the philosophy behind EHRs
    themselves. EHRs are meant to consolidate information and make the appropriate
    dissemination of patient information efficient. That is currently limited by
    data input methods (i.e. keyboard and screen), which is a design limitation. The
    future of EHRs is in “smart physicians offices”, where all the
    tedious patient induction information is integrated into EHRs automatically.
    For example, height, weight, or a quick blood analysis collected
    by rulers, scales, and smart meters, respectively, will be wirelessly
    transmitted over a secure local Internet connection to the active EHR. Even the
    Xbox 360 Kinect sensor, which uses infrared and optical tracking to map people
    in 3D, could be rigged to deliver height and weight data in a quick second scan.
    That’s less information that the physician has to enter into the computer and
    more time he/she gets to spend with the patient.

     

    I think an
    important qualification to make here is that EHRs are brand new and still
    evolving. As keen as EHR companies are to tout their product as the new “EHR
    2.0”, we are nowhere near the efficiency and efficacy EHRs could deliver to the
    clinical practice. We’re just beginning to tap into the potential.

     

    For example, a
    reader commented
    on my blog about the woes she’s experienced with an EHR as a patient,
    particularly with her prescriptions. Her story is a prime example of kinks in
    this evolving system – kinks that will eventually be overcome. A recent study
    by Abramson
    and Bates, et. al. in the Journal of the American Medical Informatics
    Association stated that in New York and Massachusetts ambulatory primary care
    settings, slightly more than 1/3 of all handwritten prescriptions contained errors.
    Now can the handwriting of physician with 25 years of experience be changed? I
    highly doubt it. Can an EHR be changed and modified to adapt and cater to a
    medical community? Absolutely. Want at least a little proof? A study by Kaushal, et. al.
    in the Journal of General Medicine showed that e-prescribing, a feature of many
    EHRs, reduced prescription errors over a two year period sevenfold! It’s
    getting better, but it’ll take a while until it’s great.

     

    Everyone wants the
    best physician possible. Everyone also wants the nicest physician possible. Considering
    EHRs allow for patient information consolidation and clear patient information
    communication, wouldn’t you want your physician to use that to communicate with
    other medical staff? What’s the use of having a doctor who will smile and nod the
    entire time you’re in the exam room, but scribbles your diagnosis and
    prescription into an indiscernible mess? The nurses won’t understand, other
    physicians won’t understand, and you’ll end up with expensive subpar care.

     

    You don’t want
    quality of care to suffer because of standardization fragmentation either. For
    example, let’s look at the backbone of medical research, the scientific
    journal. Before Pubmed came about in 1996, finding resources and references for
    a new research venture probably was a pain. After the NIH came in and
    standardized the way scientists look for information, searching for relevant
    scientific articles across any journal is as easy as doing a Google search. The
    scientific value generated by that simple act is probably exponential. That’s
    the power of standardization. 

     

    The only way to
    find out how EHRs can be improved is through application. As in medical
    research, the only way to know if a theory, therapy, or technology works is
    through trial and error, in vitro, in
    vivo, and longitudinal studies. The same applies to EHRs. Sooner or later,
    we’ll have a working model that’ll make most medical staff happy.

     

    2. I
    understand some physicians have had bad experiences with EHRs. The flipside
    could be equally supported – plenty of physicians have had positive experiences
    with EHRs. Technology in 2012 is much more advanced, and hopefully user
    friendly, compared to what was available in 1997. A bad experience with an EHR
    when the technology was embryonic shouldn’t be used to discredit the potential
    it offers for the future. Modern medicine is at the nexus of many different
    fields that have much to contribute. By stifling the possible contribution of
    ancillary fields, physicians will slow the progress of medicine. For example,
    when minimally invasive surgery first arrived on the scene, it can be safely
    assumed many surgeons demeaned the idea as uncertain. Now, however, it’s a
    staple in many operating rooms and has been refined to the point we use robots
    like the Da Vinci machine to perform these surgeries. Innovation in medicine
    has always been about improving access by making better practices cheaper. EHRs
    are well on their way towards achieving that goal.  

     

    3. By saying that
    physicians don’t have the time to learn new systems, you’re partly proving my
    point. If they are going to have to learn an EHR system, why not learn just one
    instead of multiple ones for all the places they consult at? Secondly, if
    physicians don’t have time to learn systems, is the blame to lie with overly
    complex EHRs or with the time crunch physicians face today? Overly complex EHRs
    are, once again, a design flaw, not a problem with the philosophy of EHRs themselves.
    How do you overcome a design flaw? Test your program in the real world, record
    results, and then edit code. How do you accelerate this process? Allow a
    medical community to choose its most desirable EHR and then improve it
    continually through community feedback. Allowing the “natural selection” of
    market competition to choose the best EHR will keep those business people you
    talked about in charge, not the medical community that actually uses it.

     

    I also believe
    medical education will play a large part in determining the efficacy of EHRs. As
    younger physicians train with new technology in medical schools, a part of that
    curriculum should be dedicated to understanding the role of technology in
    modern medicine. Specifically, that technology like EHRs shouldn’t be used as a
    crux, but as an aid. The physician patient relationship is still of primary
    importance. Ideally, both patient and physician want to interface with another
    human, not a screen.

     

    4. Lastly, I didn’t mean to insinuate that I
    scolded this physician for not using an EHR. I was very gracious with him and I
    simply inquired why he didn’t use one, not that he should use one (which is
    completely his decision). There’s a key difference there that I hope is clearer
    to you now. This very experienced physician has known me for 15 years and we
    are on very good terms.

    5. When it comes to open discussion, you don’t
    need to have letters behind your name to make an appreciable difference.
    Granted, experience counts for something, but flaunting academic elitism isn’t amenable
    to innovation. Everyone can have a say, but you don’t need to disparage him or
    her for doing so. I hope ellendastork and windingmywatch are bit more open
    minded in regards to different perspectives in the future.

    Yes, I understand I am a premed, but in no way
    do I feel that is a hindrance. As a student who wishes to enter medicine, I
    find myself uniquely positioned to grow with this rapidly expanding field. Accessing
    this through social media platforms like my blog, Twitter, or KevinMD, are
    great ways for me to voice my own opinions, however naïve they may seem, and
    learn from others. This is an unrivaled opportunity for dialogue. I hope to
    learn from you, your experiences, and your views. I think by disregarding what
    I say simply because I am a “premed” robs you of the opportunity to teach and robs
    me of the opportunity to learn. With that I invite you to contact me on my
    blog, my email (thebiopsyblog@gmail.com),
    and Twitter so we can continue the discussion.

     

    Warm regards,

    Roheet Kakaday

  • Thomas Lukasik

    >> “..nearly an entire hour had been dedicated to writing. Wouldn’t an EHR system make his workflow a lot smoother?”

    Smoother? Not to sound like WJC, but that depends on how you define “smoother”? If you are implying that the doc would spend less than that hour if he had an EMR, then you are assuming too much. I routinely witness doctors working from 5 or 6 PM until 9 or 10 PM on weekdays or having to go into the office on Saturdays or Sundays in order to keep their EMRs fed with clinical notes and observations.

    If that’s a smoother workflow, it’s certainly not a faster one.

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