THCB

Killer Features of the Next EMR

iphone search

I was absent-mindedly playing with my iPhone today and took special notice of a feature I have rarely used before. If you swipe all the way to the left on the home screen, you will get a search bar to search all of your iPhone. This includes contacts, iMessages, and apps. I’ve never needed to use this before—a testament to the iPhone’s ease of use. Just prior to this, I was working on some patient notes using my hospital’s electronic medical record (EMR). In contrast, each task I performed required a highly-regimented, multi-click process to accomplish.

Criticizing EMR interfaces is a well-loved pastime among clinicians. Here, however, I am going to take an oblique approach and reflect instead on what has made good interfaces (all outside of medicine, it turns out) recognized as such.

Speed

The Google Algorithm often gets credit for Google winning the Great Search Engine War. Indeed, there are whole teams dedicated to improving it. However, if you compare algorithms today, even 5 years ago, the differences in results have been only marginal. How does Google stay ahead? Speed. Google has done extensive research to determine what keeps users coming back and it is unequivocally speed of results. It has been much of the motivation for creating their own browser (Chrome) and operating system (Android). Speed means more searches and more searches means more money for Google.

Search

With EMRs, wait times to store and retrieve data can be extremely long. Moreover, it frequently takes multiple clicks to get to the precise page you want, further compounding the problem. But how slow is slow? Research in web user behavior indicates that 47% of consumers expect a web page to load in 2 seconds or less and that 40% of people abandon a website that takes more than 3 seconds to load. It regularly takes over 3 seconds to retrieve an important piece of data from an EMR. That makes the experience constantly frustrating; I wish there was another EMR I could switch to. (As a fun aside, I often find myself logging into two computers side-by-side in the hospital to save precious seconds waiting for the computer to load.)

Interface

A highly-regimented click pattern to obtain results means that you have to be constantly aware of what you are going to click next. Compare that, for example, to the Facebook Newsfeed where the next step is always “Scroll Down.”

Fortunately, consumer web has discovered a better way for reaching your destination. Why not let people search everything in one place and guess at what they’re looking for? Examples include the iPhone search I opened this post with, the original Awesomebar on Firefox, and, of course, Google search (which lets you type in flight times or conversions like “lbs to kg” along with your usual searches). The main point is that you have one destination from which you can intelligently, semi-algorithmically branch off into any workflow you could need whether that is texting a friend or searching for the air speed velocity of an unladen swallow.

The trouble is that it is hard to do this “awesomebar” search well without knowing what the clinician is looking for. What do you mean when you start typing in “echo?” Which patient are you talking about with the first name “Rose?” In fact, this has been attempted before in healthcare in the form of Amalga, which was sadly mismanaged after being purchased by Microsoft from its founders. In principle this is very doable, vendors just need to listen to and understand their users. It’s been said before, but EMRs would do well to involve clinicians in the design.

Interface

This is often cited by users as the most frustrating part of the EMR experience and so I am not going to dwell on it. Cluttered interfaces and uncertain visual hierarchy both make it harder to use software. I hope it is clear from the above that even a nice visually-appealing interface can have problems if it doesn’t incorporate speed and search.

Conclusion

Of course, the ultimate problem is that EMRs are enterprise software, where the payers are not the users (clinicians) but rather the executives who are thinking about how this will improve the bottom line. I don’t see this changing anytime soon, moreover, as consolidation and physician employment (rather than self-employment as has historically been the case) becomes more popular. The popular EMRs do a good job of making sure hospitals get paid, but they do not do a good job optimizing for speed, search, and interface. If it is going to change, it will have to come from the small concierge practices that are emerging with novel clinical and financial workflows requiring custom solutions.

 

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BennettfitnessbabesdailysribeGranpappy YokumCraig Monsen Recent comment authors
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Bennett
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Quick comment:

You probably don’t want to use the word “killer” when talking about health technology.

fitnessbabesdaily
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Thanks in support of sharing such a nice idea, article is pleasant, thats why i have read it fully

Peter1
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Peter1

The last time I had the opportunity (there was no need) to access my EMR is when the doc emailed me that my lab test results were available online. The problem was all the different interconnected curtains of security necessary to just get there. I had several failed attempts and was just frustrated even though I’m pretty good with computer stuff.

Did it once and that was the end.

SteveofCaley
Guest

There is a dark side to this cheerful and sunny gathering of data for patient access. You know, Peter, you DID have access to your records, you simply CHOSE not to review them. This will become a critical point in the litigation over care. The attorneys will snap this up like chum. “Ma’am, so you are telling the court that all this time you had access to the results of your breast biopsy showing cancer – you just couldn’t take the time yourself to look them up. And now you are complaining that someone ELSE should have told you the… Read more »

Peter1
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Peter1

Steveo, think about what you just said. I had access, but the doc ordered the tests AND has an obligation to schedule an appointment to review the results, or do a followup phone call. The test results go to the doc first, to me it’s mostly a courtesy.

Perry
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Perry

I agree with this wholeheartedly, Peter. The problem is like so many others with these systems, the patient supposedly has access, but can’t always get through to the portal, etc. In the end, we need to continue the doctor/patient encounter to discuss the results.

SteveofCaley
Guest

Yes, but as the system “matures” and the patient becomes more “empowered,” all that may be just a mask for the shifting of liability back onto the individual. Attorneys WILL use that point to push the liability onto the patient, and their IT teams will come up with reams and reams of “data” showing the ease of use for the patient, etc. So far, it’s a courtesy – but courtesies do not live long in front of insurance companies and lawyers. In our tolerance for deepening bureaucracy, the solution is often buried under ” the patient supposedly has access, but… Read more »

William Palmer MD
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William Palmer MD

I keep thinking that maybe the sweet spot in the degree of digitization of the medical record was about two years ago before the grand digital mandate. At this earlier time we had incorporated about as much computerization as the natural evolution of medicine demanded. It fell into place and was not forced. We had laboratory results, radiology, anatomic path, echos, EKGs, vascular studies, EEGs, drug incompatibilities, tumor staging formats, discharge summaries, and a few more items I have forgotten, all in digital formats or at least in text which could be scanned. Alas, now it feels artificial and forced… Read more »

SteveofCaley
Guest

Thanks, Bill, wonderful points. It is vital for those pimping the New Medical Revolution to insist that doctors are opposed to meaningful reform for selfish parochial purposes. That “New Revolution” is merely the same story that has gone on since Medicare and insurance came on board, and the testing and utilization question became adversarial between doctor and payor. But that is a long and somewhat tangential story. You touch on a vital point with AI and diagnosis, although it is not the medium itself – reading Harrison’s is enough to get one well into any subtleties of rare and arcane… Read more »

John Irvine
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John Irvine

The analogy I see is to the early days of the internet when it looked like that a select group of Silicon Valley companies would completely dominate the tech revolution, stifling all competition. Remember pre-Google search? Remember your old desktop PC? Remember your dial up modem? Remember the original Netscape browser? All examples of technology getting better in hurry, at the very moment when it seemed all progress was stalling and we were going to be trapped using stuff that didn’t work very well. Do a select group of tech companies dominate the industry? Sure. Several of the larger players… Read more »

SteveofCaley
Guest

There is a huge difference, John, between what is not perfected, and what cannot be attained in the first place, given infinite resources, time and patience. The Technopaths deny that anything cannot be attained. They are a few generations ahead of those who built the unsinkable Titanic – absolutely unsinkable in theory, no doubt. The political parallel is seen in Pyongyang – ” those wishy-washy Russians and duplicitous Chinese gave up on Communism, just before victory was achieved! Only the Great Little Leader has continued on undaunted, and the Perfection of the Workers’ State is within his far-seeing vision!” The… Read more »

Granpappy Yokum
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Granpappy Yokum

“Remember pre-Google search? Remember your old desktop PC? Remember your dial up modem? Remember the original Netscape browser?”

Yes, and I also remember that everybody used them voluntarily and thought they were great, an obvious and immediately beneficial step forward in sharing information. Only in retrospect do they look bad.

But now we’re only using EMRs because we’re paid to/forced to, and everybody hates them.

Big difference.

sribe
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sribe

But the internet revolution did not have a pile of government regulations forcing piles of features some of which were not useful, and, more importantly it was not hobbled by a federal government forcing the use of backward, outdated development methodology. I assure you, had internet applications been hobbled by the likes of the meaningful-use certification process, that revolution would never have happened.

SteveofCaley
Guest

And was not given $28 Billion dollars of Federal Money to go out and design things up-front, like the EMR/EHS/HIT.
One of the reasons that the swarms of e-Fleas are all over medicine was that they were given forklifts-full of cash to “get something done.” It worked as well as the same approach to the warring parties in the Iraq War, I expect.

SteveofCaley
Guest

At the risk of sounding unkind, these are peripheral aspects which do not express much about the guts of the EMR. My next car should have windshield wipers that sense the variability of a light mist, based on the power needed to sweep the wipers across the glass, and adjust them accordingly. My next car should also have great airbags and brakes and passenger restraints so we don’t get killed. EMR’s, like the Microsoft Office products, have a massive amount of features that are unused, and do not offer a benefit to the user. The medical EMR does not seem… Read more »

Craig Monsen
Guest

Interesting point. I take for granted that EMRs have to contain patient data (meds, labs, problems) just as you might take for granted that a car needs a steering wheel, wheels, etc.

There may be interesting conversations to have there, but I think the concept of the EMR is sufficiently mature to start talking about things you describe as more “peripheral.” Moreover, I hoped to demonstrate that these things are sufficiently commonplace in other domains and easy to achieve. However, they are not prioritized for reasons I describe above.

SteveofCaley
Guest

I caution you on that, Craig. Both the BMW and the Wartburg were German-made cars; the BMW from (West) Germany, which survived, and the other from East Germany, which did not.
The concept of an EMR is still a Wartburg or Trabant. The dull and necessary details have to be brought into tighter specification. Otherwise, you have a clunker that is barely worth keeping going.

Bubba For President
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Bubba For President

While we’re on the topic – an EMR that revealed pricing information for tests, procedures etc – would do wonders to hold health care spending in check

This IS something that should be tied to certification.