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 I posed at the end of my last post, 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, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind), where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.
Great blog! Do you have any helpful hints for aspiring writers?
I’m planning to start my own blog soon but I’m a little lost on everything.
Would you propose starting with a free platform like WordPress or go for a paid option?
There are so many options out there that I’m completely confused ..
Any tips? Kudos!
I worked on an ambulance, and helped develop the state EMS forms. An important consideration was to document signs and symptoms, so as to allow the ER doctors to diagnose the problem.
Later, I worked for a large computer company , and helped develop a case management system that would help tech support diagnose and document computer problems. Our customers were large companies and small countries (as we liked to say), so the CMS system was extremely complex and designed for collaborative efforts to find and solve the problem.
When I needed a project as part of Six-Sigma training, I thought of EMR. The problem with all the systems I had seen at that time (2001) was that they were adapted from insurance reporting systems. They focused on justifying a particular diagnosis, and often required a diagnosis first before other information could be input. This was completely backward. Instead of an “incident” starting with the diagnosis, I wanted to start with the chief complaint, in the patient’s own words. I wanted to foster brainstorming and collaboration, and only incidentally feed a diagnosis into a separate insurance module.
Unfortunately, after 9-11, the company laid off half its workforce, including me, and I never pursued that Electronic Medical Record Case Management System.
I would, however, be very interested to hear of any EMR systems that have arisen since then that have the capabilities I envisioned at that time. What I have read suggests not – that the diagnosis/insurance model still predominates. I would love to be mistaken.
By the way — I should have said this first — I love your vision, and the possibility of including the visual display of data you mention is fantastic!
The wiki model is brilliant, and another component might be an interface with the many phone apps that allow a patient to keep a health, fitness, or nutrition log.
Great article Rob! The importance of “communication” over documentation resonated with me. Our company has built a cloud based answering service that allows doctors to streamline and centralize all after hours communications and access it in real-time on any device. Doctors can immediately conference in a patient who calls or provide a one way voice message back. Improving communications between doctors and patients is really important. And yes, there are actually doctors out there who respond to their patients when they have questions 🙂
I like the idea of the bumper sticker. My wife told me the other day that she didn’t like her doctor. He wasn’t good nor bad. He was just there. I said then let him go. Let’s find someone else. So she did. Anyway I actually think your idea would make a real mark.
Your new “Collaborative Health Record” (the Google “CHR”) definitely needs one human-centered design feature that will make it easy for both physicians and their patients to efficiently view and share the cumulative results of all available diagnostic tests for the first time. It is a clinically intuitive, EHR and PHR-agnostic standard reporting format that can transform fragmented test results data into integrated, actionable information.
Your EMR must be very efficient because you hae more time to blog!
You came through! I asked for what a ‘good emr’ looks like and the very next day… viola!
I see EMR going the way of communication/interoperability already. Patient Portals, HIEs, portable CCDs. I think your gonna get your wish on that(albeit too late)
of everything you point out the thing that makes the most sense is data visualization! Thats the kind of meat and potatos I was looking for when I asked for an example of a ‘good emr’ from a physican standpoint.
I support an EMR and there are trace elements of that, but its no where near what you describe.
Thanks for the insights!!
Thanks. Yes, your comment and other made me feel I needed to get the post out while the topic was still hot.
The problem I have with portal is that it still lives in the world of data ownership. I agree that the collaborative record is more radical, and I suspect that it will be driven more by patient demand than anything else. Hopefully guys like e-Patient Dave will help champion this cause. The real goal is still the same: to focus on care and communication.
Rob, You’re describing what we’re working on for the past few years. I’m wondering if you spoke to Ida Sim with Open mHealth at the mHealth Summit. I think she is also a fellow traveler. The problem we’ve spent most of our time on is the platform for safely and securely sharing information among different systems and apps. She’s also working with that in the app world – smaller amounts of data with constraints that are different from what other systems might need – I think it would be useful to talk to her as well.
Nice update to ‘evangelist’ Rob.
To all: We discuss Rob’s journey on this week in health innovation, a deeper dive into ‘Death of An Evangelist’ and his upcoming HiMSS13 Keynote on the intersection of ACOs, quality, and ‘medical homes.’ Some may find a direct practice opting out of Medicare to be an awkward voice in the ACO conversation. Learn more:
You just nailed it Rob! We’re all geeks for that matter.
I recently had a conversation with my college professor who’s a medical historian. He told me that economics would do for medicine in the 21st century what science did for it in the 20th.
I agree with what you say about the trajectory of EMR and telemedicine, but I’m skeptical of the costs. As we all know, there’s gold in ‘dem hills because of policy reform and I bet any company, even Google, would like a piece of that $20 million pie especially if the services the provide are reducing medical costs.
Meanwhile, students my age are running around our local hospitals giving ice chips and coffee to patients, calling it “one-on-one” patient interaction when we apply to medical school. Why not put us to work as scribes? Students are easy to find, they’re cheap, they come in the dozens, and most of all – they constantly strive to learn and do better.
Rob-I think I’ve mentioned this in a previous post to this when you’ve talked about hiring IT guys to help patients with computers. Pre-health students, current medical students, allied health grad students…they could all be put to use. This sounds like reinventing the wheel of course, as I’m sure you’ve already thought about this–but have you ever reached out to MCG/Georgia Health and Sciences University? I only ask about them in light of the proximity.
I am actually going to start out with my son, who is a senior engineering student at Georgia Tech and who my patients will lavish with goodness (and cookies). When he comes home on spring break I am going have him do this. It’s a good starting point and a way to test the idea. He’s a good kid and will get automatic props for being my son. If it works from there I will look to other options (and the one you mention is a good one).
Your #1 is my #1-with-a-bullet, always, in every industry. Documentation is important – *very* important in healthcare – but communication is critical. If the tech doesn’t make the system it’s designed to work within work better, what’s the bloody point?
#3 is the thorniest issue faced by EHR technology: vendor-lockin and the gold rush mentality that drives it. Which is so 1970s, and takes me back to the olden days of Management Information Systems (MIS) and tape drives, which I used to hear my elders doing a disco version of head/desk about. By the time I was playing with data, desktops were ascendant and tablets were coming on line.
Open-source can drive so much more acceleration in data management, but much current HIT thinking is like a trip in the way-back machine to data ownership as Rule 1. What’s next – leisure-suit scrubs?
Great post Rob! We’ve incorporated quite a bit of these points and philosophies into Patients Know Best. We think the real key to making this kind of communication and collaboration happen (esp with the patient) is to put the patient in control of the record and let them invite their care team to collaborate in one secure space.
The UK government recently commissioned a global study of the various personal health records and patient portals and ranked them on a 4 point scale. PKB was the only one to achieve all four levels and quite a bit has to do with the points you make. http://blog.patientsknowbest.com/2012/07/23/guide-to-health-records-access-highlights-patients-know-best/
Thanks again for these thoughts!
There are three kinds of Data: Master, transaction and analytic. Master data is a record of your practice. It changes but slowly. You can think of transaction data as patient clinical data, which is updated at least every office visit. Analytic data are statistics reported in publications. Your EHR/EMR system should be able to generate reports, with some basic analytics.
EHR/EMR systems fall into a class of systems called Decision Support Systems (DSS). DSS systems are about making smarter decisions.
Smarter in what way?
Smarter wealth creation: Identify who you can charge and how much you can charge and still comply with the rules
Smarter patient care through Communication: Engaging a patient in automated ways. Utilizing, texting, email, video conferencing and more to improve patient accessibility. The interview process: Advance communication skills designed to extract information. Encourage and structure, patient preparation for an office visit and more …
Smarter patient care through Process Optimization: Look for better ways to manage your practice. Focus on the patient experience first, efficiencies second. Common issues are extended times in the waiting area and unprepared physicians.
Smarter Patient Care enabled by technology:
Communication improvement tools
Process improvement tools
Analytics: Collect clinical data, export it to a global resource, design interesting and relevant analytics, which focus on improving patient outcomes. The behavior patterns and trends discovered, deliver insights. The insights can be used to modify patterns and trends in ways, which improve patient outcomes.