The EHR user interface and my personal moment of Zen

Every time someone publishes an article or a paper or a blog post that has anything remotely to do with electronic health records (EHR), there is usually a flurry of reactions in the comments section, now available in most publications, and these always include at least half a dozen anonymous statements, usually from clinicians, decrying the current state of EHR software, best summed up by a commenter on THCB: “It is the user interface stupid!… It has to be designed from the ground up to be an integral part of the patient care experience”. Can’t argue with that now, can you? Particularly when coming from a practicing physician.

And why argue at all? The user interface in any software product is the easiest thing to get right. All you need to do is apply some basic principles and tweak them based on talking to users, listening and observing them in their “natural habitat”. Having done exactly that, for an inordinate amount of time, and being aware that most EHR vendors were engaging in similar efforts, I found the growing discontent with EHR user interfaces somewhat inexplicable.  The common wisdom in EHR vendor circles is that doctors are unique in how they work and whenever you have two doctors in a room, there are at least three different preferences in how the EHR should present itself. As a result, you will find that most mature EHRs have dozens of different ways of accomplishing the same thing. These are called “user preferences” and are as confusing as anything you’ve ever seen. Hence the notion that if you spend enough time configuring and customizing your EHR upfront, you will increase your chances of having a less traumatic EHR experience down the road. We were an industry like no other, doomed to build software for users with no common denominator, or so I came to believe, until one afternoon in the summer of 2006 …

My personal moment of Zen occurred in an unremarkable little primary care practice somewhere in the Pacific Northwest, where a kind and wise physician offered me a chance to play doctor, right there in his cramped exam room. He handed me his shiny new tablet and sat in the patient chair across from my rolling stool. I saw that as the perfect opportunity to teach the doctor how to use “my” software. I designed large portions of it and I’ve done hundreds of “live” demos of patients with diabetes, hypertension, COPD and “by the way” to showcase the ease of use and uncanny abilities of the EHR to simplify the most onerous tasks. And then he started talking. A simple visit. A little bit of gout. Some stiffness when climbing stairs and he didn’t like his new blood pressure meds. I couldn’t keep up. I couldn’t find the right templates fast enough. I couldn’t find the right boxes to click on. I tried typing in the “versatile” text box. I am a lousy typist. I tried to write stuff down with the stylus in the “strategically located” handwriting recognition box. I kept making mistakes and couldn’t erase anything. I tried to type code words for completing the note later. My head was down and I was nervously fumbling with the stylus and the tablet keyboard and my rolling stool kept moving unexpectedly. I would have killed for a pencil and a piece of paper. I finally looked up in total defeat and saw the good doctor’s kind smile, “now you get it”. Indeed.

A recent TechCrunch article is quoting Prof. Christensen’s (of Innovation fame) assertion that “Understanding the customer is the wrong thing to do — it’s confusing”. It seems that Prof. Christensen believes that “what’s really important is understanding the job that customers are trying to accomplish, and only once an entrepreneur truly understands the need that a product or service fulfills for the buyer can they optimize their business or product”. I couldn’t agree more. So what is the job that EHR customers are trying to accomplish? What need does the EHR fulfill for the buyer? Are the job and the need one and the same? They are not, and the difficulty in creating an interface that satisfies EHR users arises because doctors love the job and hate the need. The job is to heal people and the need is to be properly paid for services rendered, including an escalating system of regulatory incentives and penalties for activities not immediately related to patient care.

Most physicians would describe their job to be the provision of medical advice to patients seeking their help and, to paraphrase Sir William Osler, most doctors will probably agree that observing and understanding the patient who has the disease is much more important than understanding the disease itself. So what can a contemporary software program contribute to observing and understanding patients? Nothing of any significance. Someday we will have intelligent software accessing sensors plastered on patients’ organs and clothing and perhaps then software will be able to assist with observation and understanding. But right now software can only offer protocols for simple and self-evident conditions. If the original electronic calculators were only able to multiply single digit numbers, nobody would have bought anything from Texas Instruments in those early days.  How about the other parts of a physician’s job? Can EHR software help with delivering babies? Or performing surgery? Or at the very least, can it assist with a physical examination? Maybe an EHR can help with formulating treatment plans and ordering therapies? Mostly an EHR cannot do any of these things, and the little it can do comes at great inconvenience to physicians, when compared to methodologies it aims to replace.

But doctors are buying EHRs at increasing rates, so perhaps EHRs cannot help with the job itself, but they fulfill a need after all. The original need EHRs were designed to fulfill was the simple need for one to be paid for the job one was doing. This is the same universal need that drives every business to acquire and use accounting software. Generating proper invoices for services rendered (claims) was the first rationale for buying software in a medical establishment. As the rules and regulations for payments became more and more complex, the need for software increased and in parallel the software began interfering with the job. And although most physicians realized that they must allow the software to interfere if they wanted to get paid properly, it didn’t require that they like this interference. Most of us pay our taxes, but this does not stop any of us from complaining about the complexity and lack of user friendliness of the tax code. Later on, Meaningful Use and other “quality” reporting initiatives introduced regulations directly into the job of physicians and their staff. EHR software, still unable to contribute much to the job, is now fulfilling a much larger and more onerous compliance need, and at least from a physician perspective, it still has to do with being paid appropriately for services rendered.

Designing an EHR from the ground up to be an integral part of the patient care experience, as the anonymous commenting physician suggested, was never in the cards. EHR software was born to fulfill externally imposed needs, and as such it was destined to be regarded with suspicion and when those needs started invading every aspect of the job, even early supporters of computerization became disenchanted with EHRs. It doesn’t really matter how many user centered usability experts the government regulates that EHR vendors employ, because it’s not about the buttons and the clicks, it’s about what the buttons do. At a recent conference I saw a presentation delivered by two primary care doctors who found a way to restore happiness to the practice of medicine. Every slide had a picture of an exam room where in addition to a happy doctor holding the hand of a sweet patient, there was a third “team member” in the background fumbling with a tablet.

Shouldn’t there be a better way? At one point shortly before the advent of Meaningful Use, there was a slight buzz in the industry regarding something called EMR Lite. A brand new notion of creating software humble enough to take on the peripheral portions of the job that could be automated with existing technology. That seed of innovation was killed off by the perpetual onslaught of Meaningful Use requirements. Should it be revived? And if so, what should it look like?

Margalit Gur-Arie is a partner at EHR pathway, LLC and Gross Technologies, Inc. She blogs at On Healthcare Technology.

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  • MarylandMD

    So what you are saying is: “It is the user interface stupid!… It has to be designed from the ground up to be an integral part of the patient care experience”.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Yes, but not just the user interface. The entire product should be designed that way, because no matter how hard you try to make it otherwise, by hiding things or tinkering with buttons and such, the user interface to a large degree, is a result of the functionality offered in the product.
      You can’t build something to optimize billing, or satisfy MU, and then slam some lipstick on it to look good for patient care.

      • MarylandMD

        Yes, it has to be designed from the ground up to be an integral part of the patient care experience.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          Just curious, since we are in agreement, assuming a product like this existed (which it doesn’t and probably never will), do you think doctors will accept the Medicare penalties and the less than perfect billings, in order to have patient-care oriented software in their practice?

          • MarylandMD

            I think you are presenting a false choice. There is no reason that an EMR that is well designed for physician practice cannot do a good job with billing, Meaningful Use, etc. It just takes work. The problem is that the current group of EMRs are designed by non-medical database programmers who start out trying to satisfy a number of requirements (scheduling, billing, data mining, etc.) with the doctor-patient visit and interaction considered as an afterthought. If, however, the whole project focusses initially exclusively on what works best for physicians and then adds the other features on later, then you have a chance at something that can work.

            Imagine how an EMR would be designed if Apple was doing it. They would think very, very long and hard about what the *end user* (in this case the doctor) needs, then simplify, simplify, simplify, then make it more intuitive, then speed up the code, and then simplify some more, and at every step go back and do a reality check to be sure they haven’t strayed too far from what the end-user needs. It can be done, but the designers and programmers at all levels have to start out realizing that the smartest or the most important person in the whole process isn’t them, it’s the end-user.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            I think you are making several incorrect assumptions based on what you perceive the state of affairs to be. Those “non-medical database programmers” are presented with their set of requirements by the market. The market is the paying customer, not necessarily the “end user”, particularly in hospitals and large systems.

            This is why, I posed the (hypothetical) question to an “end user”. If you had to make a choice, which of the three items would be rated “must have” and which of the items could be compromised if there was no other choice, or at the very least which one should be done first?

            Truth is that I personally don’t know anybody right now that would purchase an EMR that is not “certified”, but many thousands are buying EMRs that are not doctor friendly. Why is that?
            I am sincerely trying to understand….

            As to the Apple process, I know it’s hard to believe, but most good development shops work that way. The difference is that Apple has very clear marching orders when developing their exceedingly simple consumer applications, while those same programmers when employed by say, GE, or Oracle, or salesforce.com, have different marching orders because they service different markets (Apple, BTW, makes no pretense at building any sort of enterprise/business software).

          • MarylandMD

            If the whole project focusses initially exclusively on what works best for physicians and then adds the other features on later, then you have a chance at something that can work.

            I wasn’t saying that Apple would design an EMR, just talking about the process of good design in general. To suggest that current EMR software is the result of a rigorous process of anticipating the needs of the end-user and a brutal process of simplification seems more than farfetched given the weak EMR offerings available so far. If the programmers think they are doing it now, then they clearly have no idea what it is like to really work to produce a product that works for physicians.

          • southerndoc1

            EMRs are designed very, very well to collect data and monitor physician behavior. Thinking you can use them to become more efficient or improve patient care is like thinking you can use a vacuum cleaner to roast a turkey. That’s the reality. Acknowledge you’ve been lied to and move on.
            That’s why our office is still on paper. I had my Zen moment, as Ms. Gur-Arie describes it, with about 10 systems being demonstrated, and decided to stop wasting my time. If something better comes along, I’m open to it.
            The market for an EMR that helps physicians do their job will probably be limited to those who have opted out of the CPT-run world of insurers and CMS. I am sure Dr. Lamberts will come up with something that works GREAT for him.

          • MarylandMD

            Those of us who have to suffer with EMRs envy your ability to sit it out for a while longer. I do like some of the features that I get with the EMR (ability to manage from home, rapid transmittal of information, no lost charts, somewhat improved legibility) but I pay a heavy, heavy price.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Perhaps a small illustration would help. MU2 has a requirement that you view certain information before you administer an immunization, and that the software records that you viewed it. The miserable developer that will be forced to put in place a mechanism that pops up that information, and actually requires that you (the doctor) must check some box on some screen before an immunization is administered, is not any happier than you are, but will still have to destroy the entire flow of immunizations administration and create another headache for you.
            Here is one I witnessed first hand, when the Surescripts thing became the law of the land, eRx software was forced by the PBMs to display formulary information and alternatives for every med separately. A nifty feature that previously allowed users to renew all meds with one click, had to be disabled and tons of mostly useless information in small crowded fonts had to be incorporated. No programmer enjoyed doing that.

          • MarylandMD

            The EMRs that I have seen were all bloated inefficient monsters that wasted physician and patient time long before MU2 was thought up and without the SureScripts interface activated. If they were the only problems, we would be blaming MU2 and SureScripts, not the programmers. But they aren’t.

            I have a lot of trouble feeling pity for the programmers and designers. They pound out the code du jour and get their pay. They should be thinking more broadly about what they are trying to do. That is where they should be ashamed.

            Perhaps a small illustration would help. The EMR we use in my group is Centricity (Logician) from GE. The software is a bloated mess, and heavily relies on a modal method for interaction and input. [By modal, I mean that once you open an template/window, you can only do what is allowed and only see what is offered by that window until you close the window. So, unless the window shows you the patients problem list (or med list, or allergy list, etc), you can't see it while you work on whatever you need to do in that window.] This is beyond stupid when designing an EMR, and shows the original designers didn’t have the slightest clue what a physician needs to get the job done. When you start out like that, the software is so far off course there is no hope of salvaging it. Modal software is 20th century, and you can’t blame SureScripts or MU2 for bad programming decisions.

          • southerndoc1

            I’d direct my frustration at whowever in your organization decided to buy an EMR using pre-1986 design.

          • MarylandMD

            I personally was not in the loop for the purchase decision. My understanding was that it was felt we had to proceed with an EMR for multiple reasons, some payor-related, some logistics related. The ‘least-bad’ EMR was selected–the pickings were kind of thin due to the strict criteria at the time (size of the EMR company, etc.).

            The biggest problem is that you really don’t know how usable software is until you have lived with it a few weeks after you are done with the initial training. I have attended EMR demos and I find them beyond frustrating. Like choosing a car without being able to take it for a real test drive or even look under the hood.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            To echo southerndoc’s comment, why did you buy it? How is it possible for a market to thrive (pre MU) with such crappy offerings across the board, and nobody forcing anybody to buy anything?

            Another puzzling phenomenon is that there are Centricity users that are (or were before MU, like Dr. Lamberts) pretty happy with the software. How do we explain that? How do we explain the Medscape survey indicating that 62% of surveyed docs are actually happy with their EMR? Not just resigned to a bitter fate, there were 28% of those, and 10% are jumping ship.

            So which one is it? Is EMR OK, but could be better, or is EMR horrible and unusable, but we’re using it anyway because….?

          • MarylandMD

            I don’t know anyone who I would describe their feelings towards their EMR as anything like “happy.” The best I have seen would be described as resigned to their fate.

      • http://euonymous.wordpress.com euonymous

        Absolutely. What we’re all saying is that a medical software suite has to serve several different masters. The accounting people need different functionality from what a diagnostician or surgeon or nurse needs. People access data in order to accomplish a particular task. These individual efforts need to be anticipated by the software and facilitated by automation, not thwarted. It’s not impossible, but it is a challenge. And an agreed upon standard interface would do wonders to make usage easier, more uniform, and more robust.

  • DavidBehar

    I am considering filing a class action lawsuit against my EHR provider, make an example of this enemy of clinical care. To deter.

    I would include the federal government as a defendant for its devastating intentional tort. It has cut my income by 40% because I am now doing secretarial work. It has destroyed my dignity, and my relationship with patients. I am now a form filler. It has invaded my privacy, because this enemy of clinical care has my computer pages kept in a secret location in another state. The metadata track my actions and location to the second. These data will always be used against me in any regulatory or enforcement action. They violate the Fifth Amendment right against self-incrimination.

    Its intent is to drive out doctors, to reduce access and therefore government expense.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Wow! That’s a radical idea…. I don’t think you can win, since the entire thing is “voluntary”, but you would probably get enough docs to join in to create some serious media buzz, and you could probably find a “motivated” lawyer to do this pro bono…

      • DavidBehar

        Isn’t a computer database supposed to increase revenue by reducing labor? If it drops revenue it is a defective product. If it slows things down, makes things worse, by causing greater waits, and less access to care, isn’t that a defect? The intentional tort is by the federal mandate to knowingly impose a method that has no validation, that does not reduce error, nor improve quality. What did the federal officials know about the outcomes of electronic records, and when. That is a subject for discovery. One effect from experience in federal employment is that this lawsuit, however quickly dismissed, will result in all officials involved to lose their federal jobs, and to deter their successors.

    • southerndoc1

      If it’s really that bad, why don’t you go back to paper?
      And definitely include the medical societies in your suit!

  • PatP

    In addition to facilitating billing, the major role of an EHR
    is to document the health of an individual in order to create a lasting record
    of the state of an individual over time.
    The EHR is used to save data and derived information about the state of
    the patient’s health including test results, current medications, allergies,
    and immunizations. This information can be used in decision making about care and can be
    shared with other providers.

    • buzzkillersmith

      The major role of the Japanese army in WWII was to defeat the Americans and take over much of Asia so as to have control of resources and cultural and political hegemony. But it failed.

  • psychpracticeMD

    Just a thought, to be a little controversial. I think EHR’s shouldn’t be the purview of physicians (such as myself). I think the record should belong to the patient, ported around by the patient, with each physician invited to contribute an update following each visit. And with physician access to the record at the patient’s discretion. Just like if the patient carries around her history in her head, and reports, or doesn’t report, information, at her choosing. The doctor keeps the doctor’s notes, the patient keeps the patient’s record, and billing is completely separate. Reduces liability, resentment, and stress for everyone involved. Now go convince the government.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      I think this vision is shared by some folks in the industry, to a certain degree. There are products out there called PHR (personal health record) and those are envisioned to be controlled by the patient. The physician EHR is supposed to be capable of sending over data to populate the PHR, and eventually the PHR could send information to the EHR, or the patient can give you access to their PHR to see whatever they think you should see.

      I don’t know if this is a good idea, or if patients will be willing to do the extra work to manage this software, and I am not sure how it will be paid for (right now these things are “free”), but if we go this route, I see a lot of duplication between the PHR and what you refer to as doctor’s notes. One thing that comes to my mind as I write this is that maybe the only thing the government needs to regulate are the PHRs (which are now completely unregulated and unprotected by HIPAA), and leave the doctor’s notes private for the doctor.

      I will have to give this more thought, but I think they won’t be agreeable to an arrangement like this because much of the stuff they are trying to measure and influence has to do with how you work in your practice….

      • psychpracticeMD

        I’ve checked out some of the PHR apps, and they seem kind of flimsy. I’m not talking about duplicating notes. I’m talking about a patient’s various physicians updating diagnoses, recording changes in medication, and reporting lab results. And I’m not sure why HIPAA would need to protect the data if it belongs to the patient.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          They are flimsy, but regardless, let’s assume a decent one can be found. How is this going to work?
          The patient shows up, and gives you some credentials, or logs in himself on your computer. You look at his records, talk about it, go through the visit, log into your own system, presumably on the same computer (or use paper charts), write your notes, including diagnoses, meds and maybe the labs are already there. You have to have all this stuff for your records.
          Are you now going to also update the patient’s software yourself? Type or click the Dx, meds changes and copy the labs over? Are you going to wait while the patient does the copying? What if someone makes a mistake copying stuff? Or are you going to want everything to move over from your system to the PHR with that elusive “one click of a button”? If so, you will need an interface, one that works with as many PHRs as your patients happen to have… It now starts to get harder and more time consuming….. and we are just scratching the surface here.

          And what if the patient tinkers with his PHR and there are some legal disagreements down the road? Is your record correct or is his correct? What if another doctor inactivates one of your diagnoses or allergies, and the next time he comes in you don’t remember to double check? What happens in a hospital, and where do they document things?

          It is extremely hazardous to have multiple copies of the same data floating around. Maybe one solution would be that the PHR is the only record and you make all these changes in there and then print a copy for yourself to add to your notes, but patients want to see the notes too, or at least the assessment and plan….

          All I am trying to say here is that this is not a simple problem to solve, even without the added burden of billing and Meaningful Use. If it were simple, Apple would have had an app for that a long time ago…. :-)

          • psychpracticeMD

            Thank you for the very thoughtful response. I actually have been thinking about this kind of PHR for a while, and the way I envision it, the issues you bring up are all addressable (I’d be happy to share the ideas with you, but I seem to be taking up a lot of comment space). But leaving those details aside, I feel strongly, and this is more of a philosophical point, that patients SHOULD be able to tinker with the data on such a system, which is not intended to be a chart. Not that I think patients OUGHT to tinker with the data, just that it should be the patient’s information, to do with whatever he likes, in the same way that the patient could walk into my office and lie to me. It’s simply not in the patient’s best interest to do so. But the idea is to give patients the respect and autonomy that will create a situation of trust with their doctors, rather than the infantalizing and adversarial, “I know all about you no matter what you tell me, and I’m the one with the ‘true’ record.” (Because isn’t the idea of an EHR to ultimately have a universally accessible patient record, ostensibly to improve care?) One of the problems with the concept of an EHR, even one that’s user-friendly and efficient, is that it’s a kind of big brother watching. Kind of like mandating how much salt one can put on one’s food. Sorry to be so contrarian, and thanks for your time.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            I do agree with the notion that physicians are merely guests in a patient’s life, to paraphrase Dr. Berwick, and I do believe that having one universally accessible record is the holy grail of health IT, and my opinion is that the universal record should be patient controlled regarding access to everything that was not contributed directly by you.

            I did write about this type of solution here: http://onhealthtech.blogspot.com/2012/01/arguments-for-universal-health-record.html

            In the interim though, my biggest concern is the introduction of massive and systemic errors created by proliferation of various versions of the same information and the increased need for “reconciliation” at every step.

            I would be very interested to hear your thoughts on this.
            My email is mga111026 at gmail dot com

        • MarylandMD

          Again, you are talking about data. How does the data “belong” to the patient? The patient can have a **copy** of the data that I managing as their physician, but they don’t “own” the data that I have in my EMR. They can have certain rights regarding that data, but not sole ownership.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            The data belongs to the patient in the sense that the patient is (should be) the ultimate decision maker regarding its disclosure or use outside your practice, which is really sort of like bolting the door with thief inside the house. If you check your EMR contract, you will most likely find that your vendor reserves the right to use your (and your patients’) data in aggregate for its own purposes. EMR data is considered more valuable than pure gold nowadays, and this may very well be one of the drivers to push data out of paper and individual offices and into the marketplace.

          • MarylandMD

            That definition of how the data “belongs” to the patient or is “owned” by the patient varies with how we usually think about how things “belong to” or are “owned by” a person, as we normally use it in the sense of a physical object. I am trying to get my head around what psychpracticeMD is proposing. It doesn’t fit with how we currently manage medical records (in paper or electronic form), nor does it seem at all a workable concept. Is there any group or country that manages medical records in the way proposed by psychpracticeMD?

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Not to my knowledge. Most countries have legal requirements for medical records retention as we have here.

            France has a card that patients hold and provide to each doctor, but it does not contain the entire record and it cannot be altered by the patient.

            I know of one small company that is trying to convince people to use a USB stick with all medical records and have doctors add their own documentation to it, but my original concern with data integrity still remains.

            The utopia of having a centralized database used by all physicians, hospitals and patient, is still in the realm of utopia and it will require that the entire system becomes a medical collaborative. Not sure if this is ever going to happen, at least in our lifetimes.

    • MarylandMD

      When you talk about the patient “owning” their health records, you are really talking about the data. It’s an interesting topic, but somewhat beside the point of the article above. The EMR as discussed above is the software and UI that the physician works with when reviewing data from and entering information into the patient’s health record.

      The whole concept of patients being the primary custodian of their health information seems a bit farfetched. I have trouble just getting patients to bring in their med list to every visit, or parents bringing shot records with them for new patient pediatric appointments! I guess a good number of patients would eventually learn to manage them, but I cannot believe that those patients who are especially challenged with health care access (poor, homeless, chronically ill) will do well as primary custodians of their health records. Do you work with these kinds of patients?

      The idea that patients would manage and edit their own medical records and be able to present them as the sole source on which a physician is to base treatment decisions seems to border on utopian fantasy. Do you regularly work with patients who ask for narcotic prescriptions?

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        I apologize for speaking out of turn, and at the risk of upsetting southerndoc :-), I believe that the natural custodian of the medical record should be the Medical Home, or the primary care doctor, and that this should be a billable activity. This after all was the original rationale behind the medical home concept. Patients, however, should have the option to decide how that record is shared, to the extent of their abilities and desire to participate. And if anybody wants to take the “do it yourself” approach, that should be an option as well. My guess would be that very few would.

        I agree with you that dumping this responsibility on the patient is a recipe for disaster amongst most populations, not just the vulnerable ones, but also the careless ones, which is most of us.

        • MarylandMD

          I am not sure I understand this “speaking out of turn” thing. It’s an open forum, anybody can reply to whatever messages or threads they want to. Heck, it’s your article we are discussing anyway!

          I have never heard that management of the medical record was the original rationale behind the Patient Centered Medical Home initiative. The initiative seems more an attempt to create conceptual framework for what good primary care is, and thereby help justify improved reimbursement for good primary care. Making sure that you have current records from all providers helping manage the patient is a part of good primary care and thus falls within that framework, but it wasn’t the original rationale itself.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            In 1967 the AAP published the Standards of Child Health Care suggesting the following:
            “For children with chronic diseases or disabling conditions, the lack of a complete record and a ‘medical home’ is a major deterrent to adequate health supervision. Wherever the child is cared for, the question should be asked, ‘Where is the child’s medical home?’ and any pertinent information should be transmitted to that place”
            This was the first ever mention of the medical home concept. Everything else came afterwards. And yes, making sure you have complete records should be part of it, but it is not specifically mentioned in any of the very granular definitions adopted today. It could be inferred, but explicitly asking that it be done, and explicitly paying for it to be done, would probably save us a lot of trouble down the EHR vs. PHR roads.

          • MarylandMD

            1967 is ancient history. The more recent usage of “Patient-Centered Medical Home” may have used the same term “medical home” but it does not take the idea of a complete medical record as its core or central tenet.

  • Dave

    Given the sad state of the legacy EMR vendors and their offerings, with skyrocketing installation and maintenance costs and and a complete inability to add value to the caregiver contemporaneously with use at the point of care, it would easier to build the business case where you would hire a scribe (to make all inputs) to shadow each caregiver. The physician can look at the patient, and we are training young technical talent many of which go on to pursue advanced healthcare careers. This model is used in the ER, it can be used elsewhere.

    • MarylandMD

      This is absolutely correct. The only physician that I have heard of that was able to go back to some approximation of their normal patient rapport while using an EMR had nurses act as scribes. But that means you have a 3rd person in the room during every part of the patient encounter. In an ER where you don’t have much say, maybe patients will put up with it, but I don’t think it is a good idea in primary care. It is quite shocking that we have to stoop to the level of dragging more people in the room in order to adapt our patient care model to EMRs.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I do like your last paragraph a lot. But I want to go back to the user interface design for a moment. I have been on the quest to find that elusive “how doctors think about xyz” for quite sometime and I don’t know if this is an absolute truth or not, but those administrative constraints on the software seemed to me as the proverbial brick wall.

    There are (were) plenty of EMR companies that were started by physicians who designed their dream EMR. The only commercially successful ones were those that integrated the administrative constraints into the product and made it more complex and cumbersome than it originally was. There was an understanding of the issue in the “jockey” community and some relief might have been forthcoming under different circumstances.

    I think that around 2008-2009 there were several well-funded folks (some were doctors) working in stealth mode on a different concept, a lighter one, but this all went to the back shelf, because honestly, nobody has the time or the funding, to step off the MU escalator right now.