This post is aimed at serving as an interlude to the “public option/death panels” discussions. No matter what healthcare reform bill, if any, is passed this fall, HIT will be part of the program. Four short years ago I was involved in the creation of a comprehensive, some would say monolithic, EMR/Practice Management/Billing system. This new product was built in reaction to the very large, very expensive and very clunky systems already on the market.
Remembrance of Things Past – The driving design considerations four years ago
- The problem – Paper charts are causing inefficient workflows in physician offices. It is hard to find pertinent information in a big chart and it is hard to analyze that information. Charts can only be accessed by one person at a time and cannot be accessed from outside the office. Charts are sometimes misplaced and may be lost during a fire or natural disaster. Every new chart costs money to create, store, pull and maintain.
- The solution – Application software that provides a computerized version of the paper chart – an Electronic Medical Record. Computers are great at storing and arranging data in all sorts of ways and formats. Computers can analyze, graph and report on enormous amounts of data. The software should be web based so it can be easily accessed from anywhere by multiple users simultaneously. No more misplaced charts and no more wasted office space and a SaaS solution would make sure the records are disaster proof.
- Constraints – The application must be pleasing to the eye, easy to use, customizable and economical to purchase. It should include standard practice management and billing features, or be able to easily integrate with such software. The application should ensure that all patient data is secure at all times.
- Insights – Medical records, whether they are stored on paper or ellectronically, are dispersed across multiple care systems. If the medical record is to be of any value, it must be comprehensive. Any provider, care giver or patient must be able to access data aggregated from all those disparate sources, either “just in time” or from a centralized location.Evidence suggests that the few providers with EMRs in their practice are having difficulties using these systems. Aside from clunky features and bug infestations that plague the majority of EMRs out there, there seems to be one common complaint: cumbersome data entry and quality of resulting documentation. Last, but not least, is the cost issue. Most EMRs are still too expensive, particularly for small practices. There are two components to cost: upfront investment and loss of productivity over time due to the complicated nature of the software itself.
- Perspectives – Any attempt to mitigate the lack of continuity in the medical record must begin with standards. Terminology and data standards, as well as communications standards. This does not necessarily imply one monolithic standard. There is room for many different ways of storing and transferring data, as long as the standards are documented and understood. There could be an industry niche for translation gateway providers (similar to the Star Trek universal translator). Of course, all standards should be open and free.Once the vast majority of providers, payers and patients have electronic capabilities, an addressing system should be created to allow “Just In Time” (JIT) access to medical records, no matter where the information resides. The aggregation should occur at the point of request and the translation gateways may fulfill this function as well. Some argue that it is better to aggregate all data in a centralized massive storage system. Building and securing such a “database in the sky” is a monumental task and the recent NHS experience suggests that this may not be the right approach. I am, by no means, discounting the logistic difficulties involved in JIT medical record aggregation, but technology is bound to advance and attenuate such difficulties.
- Musings – The other day I was doing laundry in my basement. I found myself staring at the washer and dryer thinking that we tried to do too much with our EMRs and the technology was not there to allow it. Think about washers and dryers. You wash the clothes in one, manually move them to its neighbor to be dried and neither one sorts or folds laundry. Yet every household has a washer and dryer. Nobody is missing the old vats of boiling water and the big old wringer. The washer and dryer industry did not insist on a perfect, complete and seamless automated process.So why are we shooting for a paperless office? Because it sounds good? Let’s face it, no other industry has paperless offices. Not even the banks.Maybe we just pick a few things that are important and do them really well, instead of doing a mediocre job for everything.Maybe we computerize only data that is both pertinent to patient care and easily captured, codified and standardized.Maybe the EMR should neither sort or fold laundry. Maybe it shouldn’t attempt to create prose while physicians are required to painstakingly click on a multitude of little boxes.Maybe we take a step back and provide simple, basic, robust and really useful tools instead of one big unwieldy glob of software.Maybe one day technology will advance enough to obviate the need for manually collecting data at the point of care. Maybe the EMR will just sit there and quietly observe the patient/doctor interaction, while continuously processing and recording pertinent data on its own. The perfect scribe. It sounds like sience fiction, I know, but so did many other things that we now take for granted, like washers and dryers.
After all the customary trials and tribulations, a software product was born. Features were added, directions were changed, certifications were obtained, and like all software applications, the EMR kept on growing and progressing on a predictable trajectory. I was fairly pleased. But, what if…?What if I had to do it all over again? What if I was starting today with a blank piece of paper (or whiteboard) trying to design the perfect EMR? Would my considerations be different than four short years ago? Would the design principles be the same? What about the implementation? Would today’s technologies be able to provide solutions to yesterday’s insurmountable problems?
Prelude to a Philosophy of the Future – Insights, perspectives and musings
So if I had to do it all over again, I would take a hard look at Microsoft Office. I would build multiple useful applications, like Word, Excel, Power Point, etc. I would make sure I can export data from one to the other. I would make sure that the user interface is consistent between them. I would allow others to create templates and integrate their software into my tool bars. I would borrow from Google and make it all web enabled and capable of communicating with all interested parties. And if I had all the money in the world, I would make it open source and free.Yes, I know, it sounds an awful lot like Clinical Groupware.
Margalit Gur-Arie is COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization.