This is what a physician wants in an EMR. Please build it.


Adding “electronic” means sortable, searchable, bigger attic, more junk. Unfortunately, no one has the guts to actually clean it. Are urinalyses from the 90s still important, or are we just being sentimental?

For everything we do in medicine, there are intended effects and side effects. During my emergency medicine residency there was a mandate that attending physicians had to see each patient cared for by their residents. While a hard transition, I think U.S. emergency medical care became far more consistent as a result. I absolutely benefited in my training, and I’m certain my patients did as well.

Then came the side effects. Instead of accepting “seen and agreed,” for legal and billing reasons attendings had to write actual notes on every chart, often using the exact words written by residents on the very same page. “Pt c/o ST. Red OP. No exudates. CV – RRR, no MRG. Resp – CTAB. Abd – soft, NT, ND. Likely viral. Rec’d fluids, rest, ibu, f/u w/ pmd.” Basically, attending notes became abridged versions of resident notes. They added nothing to patient health, but further buried useful information and slowed care.

Back then if you requested a patient’s records, minutes to hours later a metal cart would arrive, sometimes with 5+ volumes of paper, mostly composed of signed consents, insurance forms, decades old labs, illegible carbon copies, admit/discharge reports, ER logs with resident plus attending notes, etc. Interspersed were the nuggets: current medications, allergies, recent procedures, last EKG, primary caregiver and emergency contact numbers. If you were lucky, you found a comprehensive recent discharge summary.

Electronic medical records offered an incredible opportunity to speed information transmission and improve care. But that promise has yet to be realized. Having worked in quite a few hospitals since residency, regardless of the EMR, I find they consistently pull me even further away from patients. I work part time in a wonderful emergency department today that uses scribes to ease the load. It’s incredible working with these bright-eyed, energetic individuals, yet I still spend far more time clicking buttons than with patients. Gigabytes of data are generated, but the nuggets remain scattered and buried. Gathering history quickly from neighboring hospitals or clinics is still no easy task. Amazingly, fax remains cutting edge for transmitting records everywhere I’ve ever worked.

I suspect no one person or agency is to blame for the disappointment that most of us feel with electronic medical records. It’s a tough nut to crack, and hopefully, we’re just in the transitional years. At least, doctors are starting to make more noise now. However, rather than add to gripe mountain, I’ll instead make a proposal, or my own bark at the moon.

Could one product or program exist with just the nuggets? I’ll be more specific. If you are a programmer, please build me one golden graphical user interface that exists on every monitor of every hospital across the globe (like Windows Explorer, but faster). When clicked, I’d like it to prompt for username and password, known only by patients, and stored on a wallet-sized card, bracelet, necklace, smartphone, napkin … no matter. Once logged in (read-only mode), I as the caregiver, enter a glowing nugget-filled virtual room with current meds, allergies, emergency contact numbers, last EKG, a 140 character PMH tweet, along with resuscitation and organ donor status. Last hemoglobin, potassium, and creatinine would be a bonus.

If you build this, I as a doctor will commit to spending 3 to 5 minutes with each of my patients during every discharge, deciding together what we may want to include in such a capsule (using a separately patient-held access code for editing). Versions of this exist in various forms, and I’ve watched others crash and burn. Unfortunately, they all seem to lose sight of simple and concise. For me, the minimum viable product is the maximum desired product.

Whether built by Microsoft, Apple, Google, our federal government, the United Nations, or Estonia, I truly don’t care. Next time I’m toes up on a backboard in Iceland, I want those doctors to know my medical high points without needing to touch a fax machine.

For those of you worried about privacy, fear not! Patients can choose to omit anything they like, or even provide false info. For my medical record, I’d enter all the info requested, because I don’t want anything slowing down those Iceland doctors. But for anyone nervous about listing sensitive information, just leave that out. Include only what you want your caregivers to know should you appear in some ER impaired, or simply speaking the wrong language. As a patient, you can lie to me verbally or virtually. As your doctor, I want to know what you want me to know to help you feel better. And I don’t care what your ten point review of systems and family history were on your six visits in 2013.

Let the top 5 to 10 billing platforms — I mean EMRs — continue to compete and improve. In parallel, I want a simple, concise and elegant system that floats above the rest to save me from grinding my teeth to the gums prematurely. I didn’t go to med school to pan for gold. Grandpa is the only person who truly knows where to find the nuggets in his attic. Let’s involve him in the cleaning.

Sam Slishman is an emergency physician.

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