Only one company can deliver the perfect EMR: Google

Only one company can deliver the perfect EMR: Google

For the record: I am a geek.  I love technology.  I adopted EMR when all the cool kids were using paper.  Instead of loitering in the “in” doctors lounge making eyes at the nurses, I was writing clinical content and making my care more efficient.  I was getting “meaningful use” out of my EMR even when nobody paid me to do it.  

But now who’s laughing?  While they are slaving away trying to get their “meaningful use” checks, I’ve moved on to greener pastures, laughing at their sorry butts!  It’s just like my mom promised it would be.  Thanks Mom.

Really, for the record, I am not so much a technology fan as a “systems” guy.  I like finding the right tool for the job, building systems that make it easier to do what I want, and technology is perfect for that job.  I am not so much a fan of technology, but what technology can do.  Technology is not the goal, it is the best tool to reach many of my goals.  There are two things that measure the effectiveness of a tool:

  1. Is the tool the right one for the job?
  2. Is the person using the tool properly?

So, when answering the question, what constitutes a “good” EMR, I have to use these criteria.

How is technology the right tool for the job?  The job I seek to do is not what EMR’s are designed for: documenting health care.  I want a tool to help me give care.  I can afford to focus on giving better care since I am no longer paid to document, which is what the health care system demands of doctors.  I spent the past 16 years using a documentation tool for care, which is definitely a mismatch.

What then would a care tool look like?  Here are the things I think are most important for good care:

1.  Communication over documentation

While data gets all the attention of IT vendors, health executives, and government drones, it is the communication of that data that constitutes good care.  One of my first goals in my new practice is to use whatever tools possible to enable that communication.  Standard health care only allows communication in the exam room (although many patients would say that doctors are so focused on documentation that they don’t listen there either).  Between office visits there is virtual silence from the patient, as if their life is not happening during that time.

I’ve considered making bumper stickers that say: “My doctor answers my email” or “My doctor answers the phone,” with my logo and web address underneath.  This is effective because of the insinuated truth that most doctors don’t do either.  The system dictates this, but good care says otherwise.  My patients have been delighted when I answer questions, view the spreadsheets they fill out, and interact with them on a daily basis.  It’s communication, and tech makes it much easier.

Documentation is OK, as long as that documentation centers on the communication of data, not just the data itself.

Yet even I use the term “medical record,” which refers to a static collection of data rather than a tool to allow that data to be used well.  Any good health IT system must not simply document the communication, but must enable that communication as to happen easily as possible.  This means both getting information from my patients and putting it into their hands.  This is why another central goal of my practice is to give patients access to their records.  Too much of patient care is done blindly, not knowing what care has been done, relying on the patient to re-recite their medical history.  With the proliferation of mobile technology, my patients can bring their medical record with them wherever they go.  This, in turn, enables better communication with other providers.

2.  Organization of data

Walking around with a computerized stack of paper, however, is not all that my patients need; they need the information to be organized.  This is another of the strengths of IT.  An astute commenter on my last post gave a link to a TED talk on the beauty of data visualization, which shows how organizing and presenting data in the right way can make dry data tell rich stories.  I want an EMR that shows me a timeline of the patient tagged with their symptoms, medications, lab results, vital signs, and any other pertinent data I want to see.  What is the relationship of exercise to your depression?  Did that back pain start after you added that medication?

The point of organization is to see through the extraneous to see the meaningful.  It is, in essence, another part of communication.  As I listen to a patient’s story, I ask questions and bring out important details they may have missed, and ignoring that which I know is not significant.  This is what makes a good diagnostician, and the ability to this with the volumes of patient data is what would allow IT to improve care.

3.  Collaboration, not ownership

The world of health IT is obsessed with something called “data ownership.”  This is kind of crazy, as data is information, and information is fluid.  How do you “own” information?  If I learn a fact, do I “own it?”  If I possess a book, does that make me the owner of its ideas?  The wonderful world of HIPAA and the threat of identity theft has bolstered the cause of “ownership.”  Unfortunately, communication of ideas is diametrically opposed to this concept.  IT must not be about building walled gardens of data, but about collaborating with that data for the sake of patient care.

I first heard of the term, collaborative health record from Dave Chase (the guy who first told me about my kind of practice), and I really like the concept.  The idea is that the ideal patient record is a collaboration between the patient and the caretakers.  Patients know things I don’t: what meds they’ve been taking, how they feel, whether they are married, are smoking, or if they had measles as a child.  In fact, if you look at a typical note in a patient chart, the majority of the information is originally “owned” by the patient.  So why not let them take care of those parts of the record?  Why not let them update when they’ve been to a specialist and had their medication changed?  Better yet, why not have the specialist take part in this too, collaborating to make sure the patient got the message correctly?

Why, in fact, do I need to re-create what the patient could do better than me?  Why not just look at what they’ve done instead of transcribing it into “my” record?

This sounds suspiciously like a wiki.  What resource on the internet gives useful (albeit sometimes inaccurate) information in a format that elementary school students understand?  Wikipedia.  Isn’t this a better way to organize patient data than a typical EMR?

4. Easy does it

In considering what I need from IT to give patient care, there is one more thing I need – something that is clearly lacking in most EMR systems: ease of use.  I should have seen the writing on the wall when my EMR vendor insisted I pay for 4 days of onsite training before I could use their system.  I don’t want to learn a new language, and my patients want it even less.  Just as a medication a patient cannot afford is useless, a technology a patient won’t use is also useless.  Tech can go either way on this: either making difficult tasks easy or making simple things complicated.  This is where Steve Jobs was right: design simplicity.

I don’t want my patients to have a separate log-in for each part of their care.  I want a single sign-in and a uniform experience.  I want an app that they press which pops up options to “refill my meds,” “contact my doctor,” “update my record,” and “look up a result.”  I don’t want them to need to own certain software or download files.  It’s got to be easy and well-designed.

Putting it together

So in thinking about this wish list, it occurred to me that there is one company that could deliver all of the goods here: Google.  Apple and Microsoft have many of the same tools, but they are far more proprietary in their approach.  If I share a spreadsheet with a patient, I don’t want to have to worry they own Excel.  If I want to do a video chat, I don’t want to have to consider if they’ve got a device that can do FaceTime.  Google does email, spreadsheets, video chat, groups, web pages, organizes data, and has lots of cat videos to boot.  And all of these services are easy to use and free.  Most of them are free.

So should Google get back into health IT?  Didn’t they already try health IT and fail?  Ah, but it’s not just having the right tool that is important, it’s knowing how to use it.

So, Google, if you really are interested in changing the world for the better, you know where to find me.  I suppose I’d be willing to talk.

Rob Lamberts is an internal medicine-pediatrics physician who blogs at More Musings (of a Distractible Kind).

Comments are moderated before they are published. Please read the comment policy.

  • Matt Henley

    “Google does email, spreadsheets, video chat, groups, web pages,
    organizes data, and has lots of cat videos to boot. And all of these
    services are easy to use and free. Most of them are free.”

    They’re not actually “free”. If you use these google products, google collects and stores your personal details, actively tracks you across the web, monitors your data and activity and sells the lot to the highest bidder.

    The cost of these “free” products is actually pretty high, depending on how much you value your privacy and personal details.

    I don’t know how I’d feel about letting them datamine my entire personal medical history.

    • http://doctor-rob.org/ Dr. Rob

      My intent is not to give them the records, but to have them provide the infrastructure on which to build them. They certainly would have no data mining rights. They do offer very simple tools to share, search, and organize data. The point of this is that we look to EMR, which is almost an archetype of complexity, to help with patient care; we need to look to something that is good at simplifying complex tasks, not the reverse.

      • amused bystander

        “They certainly would have no data mining rights.”

        There are lots of rights which Google were never granted, but which they took anyway.

        They deliberately engineered their system to secretly over-ride Apple’s “Safari” browser’s user privacy settings, so that they could harvest data they had no right to harvest.

        That is just one of many indiscretions. Mention “Google” and “Patient Health Records” in the same breath and don’t be surprised if many of your more tech-savvy patients run away screaming “HELL NO!”

    • Caitlin Peebles

      I remember when there was a huge glitch in Google Docs a little while back and millions of “private” documents were made 100% public. There was another “bug”/”feature” in 2010 which let hackers mass-harvest email addresses and other personal data from the system. Talk about “sharing” your data!

    • Jack

      A bit overblown – they don’t sell the information to the highest bidder, they match the information with advertisers who are interested in selling their products. The advertisers never see the information, they only input what sort of customers they’re looking for and Google matches them.

    • http://profiles.google.com/gmlevinmd GARY LEVIN

      Google has it’s own goal for using it’s data that has nothing to do with ‘selling’ it for revenue or other profit making goals. Ray Kurzweil inventor of the synthesizer also is one of the founders of Singularity University explains it this way. He posits that Google will use all the data from Google + social media, emails and docs to develop a data base to be used in natural language processing to develop Artificial intelligence machines…..

      • http://twitter.com/sarasteinmd Sara Stein MD

        Good luck with that! Considering most of the “intelligence” they’re mining from social media and emails. If it works, we can replace Congress with droids.

  • southerndoc1

    If Google were to design an EMR to fit our current ICD/CPT/MU/HIPPA/JCAH/med mal system, it would be identical to what we have now.

  • http://twitter.com/brandcaptain Larry, Brand Captain

    Great article. Healthcare is a tough nut to crack, even for Google. Patience and an identity that is unique and emotional is key. Google missed that part. Healthcare is different than most brands. Earlier today, I had lunch with a CMO of a very large hospital system that was awarded corporate marketer of the year for 2012. He said it best, “We are selling life.” So its emotion and lifestyle branding that is key over services and technology promotion. Good luck out there.

    • southerndoc1

      Pretty much sums up everything wrong with our health care system.

  • http://twitter.com/shihjay2 Michael Chen

    Rob,
    In my quest for a “perfect” EMR, I had very much the same vision as you did. When the whole Meaningful Use incentive legislation nearly doomed my practice to extinction due to the extravagant costs involved in keeping my existing EMR, I decided to build my own. And since Google wasn’t going to dive into EMR market (anytime soon, or ever) I decided to build my own with the same underlying principles.
    1. Free (or low cost to maintain) = mine is open-source, no cost
    2. Intuitive user interface = mine looks like something that google would make – no training needed!
    3. Easy to understand database framework so that the data is easily portable from one system to another == collaboration, it does continuity of care records and it can recieve lab results and send prescriptions with Mirth as a translator
    4. Follows the physician workflow from beginning to end = see my live full featured demo.
    After dumping all of my existing knowledge in php, javascript, and mysql – all of which can be found in Google, Amazon, and other large-scale web services, I had created my own that is open-source (no cost to purchase, ever) for all physicians to able to use. It has been released nearly 6 months ago and it’s been making the rounds worldwide. It is not the “panacea” EMR as hospitals are different beasts, but for ambulatory (outpatient) EMRs, especially those that are independent and small, my EMR is totally geared for this audience. My patients loved it because it also has a patient portal built in so you can message directly to your doctor and review your records and lab test data. It’s called NOSH ChartingSystem. Google it and you can find it there. Check it out!

    • http://doctor-rob.org/ Dr. Rob

      I was scared off of doing my own EMR by a couple of friends who built one themselves. I am really looking for something that enables my kind of practice – not one that forces me into a box, but one that gives tools to do medicine in a different way. I’ll look at NOSH (and am talking to guys at the Open-EMR project as well. My MO has always been to only use the parts of IT that make my job easier, ignoring the rest. Will likely do the same as I build something (have help building, I hope) that will work in my new business.

      • http://twitter.com/shihjay2 Michael Chen

        The nice thing about doing this the open source way is that you can modify the project to however you want. If you feel like you have the technical expertise to do so, you can do it yourself without violating your software license. The way this project works for me (and how I get my income from the project) is that I can help those that have an idea of what they’d like to see in NOSH and I customize it for them and most of these ideas end up in the product that is released for others to use as well. It’s totally a community and physician driven process. I have several clients that have made considerable contributions to the project over its incarnation in the past 6 months. Electronic prescribing is the next big thing coming up and which is associated with an upcoming Kickstater campaign in the next few months, which is real exciting. Thanks for looking into it!

  • http://twitter.com/drcarolw Carol Wilkinson

    Great article with a lot of great points on what is lacking in our current EMRs. They are outdated technology and the big winner doesn’t have motivation to improve. Worse there isn’t open access to APIs that would allow for all the talented relative designers and programmers to build integrative application that could allow for communication, data visualization, better sign out and task lists etc. I don’t however think google is the answer. Sure they are great for sharing documents an searching for things but they have been less successful in the user experience and social media arena….

  • http://twitter.com/ZibdyHealth Zibdy

    We are working on our platform, ZibdyHealth, for past two years to get everything you mentioned in this post without Google name and user tracking. We have released our first generation product for patients only. Our goal is to make it share data seamlessly with all EHRs via CCD/HL7 standards so absolutely no restriction on sharing. Patient will be able to share data with their family or let family manage it for them. It is free and we plan to keep it that way.

    Please check it out and give us your feedback. Our goal is that patient or their caregiver should not spend more than 10-30 seconds to get useful information from our platform. We rather have patient spend time on something more meaningful (pun intended) in their life than decipher medical jargon.

  • http://profiles.google.com/gmlevinmd GARY LEVIN

    Clever image….illustrating the multi-colored aspect of the Google trademark branded Logo. Bet most people did not catch that…Another llama award to the Lambert !!

    • amused bystander

      “Clever image….illustrating the multi-colored aspect of the Google trademark branded Logo. Bet most people did not catch that…”

      Dude. That widely-circulated photo is of Google’s data centre. Anyone who reads Wired, CNET, SlashGear or TechCrunch would have “caught that”. Anyone on Twitter saw it making the round six months ago. What is this, “the land that time forgot”?

      • http://profiles.google.com/gmlevinmd GARY LEVIN

        During my last several visit to the Google Plex for a meeting with Serg and Larry I did not get to the basement.

  • http://twitter.com/chauser827 Christine Hauser

    Just spent an hour writing a lengthy, but very important and heartfelt reply to this article. And then……I lost it before posting. Do not have the stamina to rewrite it…… ahhh!!! I will sum it up succinctly this time……. THIS IDEA WILL TRULY CHANGE THE WORLD! It is brilliant. For healthcare workers trying to manage and communicate our patients’ care efficiently and simply, an EMR such as this is long overdue. For ALL of us, as patients, it will truly be life changing! So, have you contacted the powers that be at Google yet?? :) Your vision is inspiring. I look forward to using this new tool as soon as all of you “smart” people out there create it and get it developed!! :) Please hurry.

    • http://doctor-rob.org/ Dr. Rob

      No, Google hasn’t contacted me, but other significant entities have. The hard part is that enabling communication is actually counterproductive to “business as usual” in health care. It’s hard for companies to see the point in building a system that will be rejected by most doctors in the system (communication=avoidance of unnecessary visits to the doctor, which pay a lot of bills). The challenge for me is pitching this type of system hand in hand with a delivery system (for me, it’s direct primary care) that benefits from communication. But opening the dialog and giving people the idea that there is another option besides our morass of complexity is a major first step.

  • http://twitter.com/vicki13w vicki willard

    I am a patient, not a doctor. I was a “member” of Kaiser MidAtlantic until my employer dropped them a few years ago. I loved being able to sign into Kaiser’s site to send my physician an email, to schedule appointments, and to get test results and copies of my records. It may me feel like I was involved in my own health care, and I want to be able to do that again.