Imagine a physician-designed EMR

The title itself should make us all cringe!  If there’s one thing I know to be true, it is that putting clinicians at the helm of electronic medical record (EMR) design is doomed to create a product with limited scope and lack of forward-thinking trajectory.  Yet, the concept of integrating and considering the physician point of view and workflow is critical to successful EMR functionality.

The question is how can clinician insight help improve value within the EMR for patients, clinicians, hospitals and practices — and how might we use these insights to evolve EMR design?

Despite varying reports on the amount of time clinicians spend interacting with the EMR, one thing is clear: the time burden is significant and unlikely to dramatically decrease in the near future.  We easily spend more time on documentation, data review and electronic patient care than we spend on care at the bedside.  This new reality can lead to a tense and constrained relationship with the patient given the decrease in face-to-face communication.  Yet, at the same time, we need to accept the presence of the EMR as a vital component of the health and well-being of our patients and the future of our value-based healthcare system.

Healthcare is a rapidly changing field and applying a blanket EMR structure to its core function seems impractical at times.  Kenneth Mandl, MD, MPH and Issac Kohane, MD described the paradox well in the New England Journal of Medicine in 2012 when they stated that the challenge is fitting EMRs into a, “dynamic, state-of-the-art, rapidly evolving information infrastructure.”  While healthcare has its own challenges with respect to its overall evolution, there are some clear trends that are begging for valuable and seamless EMR integration and redesign, including:

Enabling patient-provider engagement.  What if the clinician’s time invested in the EMR was seamlessly transformed into well-designed, patient-facing data and insights?  While personalized health records and portals are being implemented across the country, the notion that our work in the EMR could be re-coded into meaningful data for the patient at the point-of-care remains largely unsolved but highly desired.  In many ways, we still under-utilize the EMR.  Reimagining the EMR as a tool to visualize and share care decisions and insight might provide hidden value for patients and clinicians alike.

Consider routine screening measures and testing in an outpatient visit for a diabetic patient — the clinician behavior within the EMR is satisfying a number of quality benchmarks and completing key documentation. Such information — checkboxes regarding presence or absence symptoms of complications, the acknowledgement of abnormal labs and the ordering of further testing – could be translated into a picture of health status for the patient. If this behavior is analyzed and displayed into meaningful health information for the patient, clinicians might obtain even greater value and quality out of their interaction with the EMR.  This would represent one step towards the EMR becoming less of a wall in patient care and more of a bridge.

Integrating evidence-based guidelines.  Evidence-based guidelines are thankfully being developed at an excitedly furious pace, with acute and chronic care being transformed because of them.  The integration of such guidelines as decision support tools within the EMR, however, is slower than one would like.

Numerous vendors exist in this space and successful adoption has certainly been demonstrated.  Any non-clinician would only need a few hours of observing clinician workflow to see how often we reference evidence and the literature while actively caring for patients.  Intelligently designed and integrated evidence-based decision support is critical to high quality, efficient care.

Aside from integration, a component that is often neglected is the clinician behavior surrounding decision support.  When and why we deviate from clinical guidelines is important for understanding our populations. For example, the decision to obtain expensive imaging in cases of low-back pain, or a CT scan of the head for a patient in the emergency department, if appropriately tracked in the EMR, can be greatly useful when analyzing exceptions to clinical guidelines as well as individual physician quality metrics. Capturing this behavior can provide individual clinicians with insight into their own practice, as well as improve the oversight on behalf of practices and hospitals.  More so, this insight would have a direct impact on patient care.

Enabling smarter communication.  In its simplest form, the EMR is a communication tool. Clinicians from every discipline and at every level use it to communicate with the patient record and, in many cases, with each other.  With overwhelming evidence supporting breakdowns in communication as critical to medical errors, developing smarter communication strategies has never been more important.

Multiple iterations of tools and icons that communicate orders and flags to clinicians, nurses and other disciplines exist.  Yet none of them seem to capture some of the important variables of clinical communication — acknowledgement and action.  When clinicians at any level acknowledge abnormalities in labs, studies and care plans, the action we take is reflective of our understanding of the data.  An EMR that can effectively and efficiently integrate this into the workflow provides extreme value for the system.  For example, in the busy emergency department, systems embedded into the EMR and mobile devices to alert providers when lab results return, when studies have been delayed or when critical actions have been completed, may make care more efficient and improve cost.

While initial efforts show promise, the intuitive and well-designed integration of such systems into EMRs remains challenging.  The question of whether and how electronic communication will ever safely replace face-to-face communication remains unanswered.  However, the need for the EMR to effectively communicate patient care and decisions to its many digital users is crucial.

While the when and how of transforming the EMR into a seamless part of the clinical workflow that provides benefit for all parties in the care process may still be up in the air, one thing is clear — there is value in tapping into the mind of the physician (and the patient for that matter) to develop the next-generation EMR.

Israel Green-Hopkins is a pediatric emergency medicine fellow.  This article originally appeared in What’s next at Nuance.

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  • ninguem

    “Physician-designed EMR”

    That was AmazingCharts, at least until the inventer/owner sold out a couple years ago.

  • Margalit Gur-Arie

    Well then, Meaningful Use Stage 3 should come pretty close to this ideal…. and I can’t remember where, but I’ve seen that picture book rendering of information in one of them recently… lots of colorful bars and stuff.

    • Dr. Drake Ramoray

      I like colorful bars and stuff. They look good at lean six sigma meetings that I used to attend. You know the meetings that took up time and resources that could have been used for patient care.

  • southerndoc1

    If this physician-designed EMR has to work in our ICD/CPT/MU/P4P/med-mal system, it will be indistinguishable from what we have now.

    • Dr. Drake Ramoray

      It would appear my sarcasm went too far as my post got deleted. Basically anyone (including the only son of a diety) , could create an EMR and if had to work in the current system as southerndoc states you wouldn’t be able to distinguish it from other EMR’s.

  • goonerdoc

    Physicians care. Everyone else, though, the answer is a big fat NO.

  • Deceased MD

    I am very sorry and can relate. I don’t think anyone knows but us. I wish we had a strong lobbyist but we are being bamboozled at every step of the way. To be honest when there is so much fighting over HC and ACA, millions of dollars spent fighting the ACA that was just passed, etc.
    I would guess that no one is aware of how this is affecting docs as well as pts. I would have to believe that with the marginal groups of people with bad or no insurance it is increasing morbidity and mortality and the same goes for our work.( early retirement or Kafkaesque work environment)
    Clearly there is so much fighting there is no awareness or lack of concern. It is frightening. Take care of yourself!

  • buzzkillerjsmith

    “Despite varying reports on the amount of time clinicians spend
    interacting with the EMR, one thing is clear: the time burden is
    significant and unlikely to dramatically decrease in the near future.
    We easily spend more time on documentation, data review and electronic
    patient care than we spend on care at the bedside.”

    “Yet, at the same time, we need to accept the presence of the EMR as a vital component of the health and well-being of our patients and the future of our value-based healthcare system.”–This guy 2014

    “Use of any drugs, alcohol, or electronic devices at this performance is strictly prohibited.”

    “But is encouraged nevertheless.”–Monty Python (paraphrased, circa 1978)

  • Michelle Boucher

    Chandresh, I would agree wholeheartedly. EHRs designed by doctors DO exist, and it is obvious when demonstrated, as the physician has that “aha” moment when they realize the workflow makes sense to them. You see, the doctor’s frustration is usually within the note, and the little tiny aspects – such as where to click, and how many times – that make repetitive work become a chore, rather than just a natural part of the process. I would LOVE to see a new, in depth type of EHR review system, where these labor intensive tasks are ranked, especially when you have companies like ours who are totally devoted to designing WITH the doctors, not for them. Our EHR team spend 2 1/2 years inside a multi-doc practice and surg center designing the EHR’s workflow by watching how the physicians work, getting their input, changing the program (in one case, rewriting most of the code to eliminate one unneeded click in a process at the request of a doctor), and then testing, testing, testing across multiple specialties. The doctors we worked with in designing the system are now our beta test sites, and no update or revision is included that hasn’t been requested and/or tested by the people who use the system. This story runs very deep for us, as we built our entire company and product on the notion that doctors are smart, and they know what they need. As a result of including them throughout the evolution of our EHR, they are able to chart and work better, and much of the burden imposed by EHRs in general have been eased such as is possible to do so. I urge more doctors to ask questions of their vendors such as, what is the phone number of the doctors who helped design your workflow? As Dr. Jeffrey Ginsberg noted after looking at 15-20 EHRs, “it was obvious doctors were involved in designing this,” You’ll know the right EHR when it works the way a doctor actually works. They do exist.

    • buzzkillerjsmith

      Too many words, too few words that make much sense.

      If an EHR does not allow a physician to enter data in the same or less time than dictating does , then it is a failure, both for docs and for their pts. Perhaps its most destruction characteristic is that it, among other factors, will lead docs and NPs and PAs to seek shelter in fields where this life-sucking technology sucks less life–fields other than primary care. Perhaps you are aware there is a shortage on. Perhaps not.

      If you were a doc, you would know this.

  • buzzkillerjsmith

    I misjudged you.You get it . Sorry.

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