Tech

The Black List: Features Which Should Be In Most EMRs/EHRs (But For Some Reason Aren’t)

flying cadeuciiI have been in the health information technology field since 1990 when I began creating ComChart EMR. It was a labor of love which ultimately evolved into a small business. From 2004 until 2012, ComChart EMR had amongst the highest KLAS rating of all EMRs in the small ambulatory care group. From 2011 until 2015, ComChart EMR was certified by the ONC for Meaningful Use Stage I. Unfortunately, the technical requirements arising from Meaningful Use mandates and changes in market conditions required that I stop selling ComChart EMR in 2015.

As a result of the 2.5 decades I spent creating ComChart EMR, I have learned a lot about which features are useful in the exam room and how to design an EMR so that it facilitates the user ability to provide medical care to their patient. As Judy Faulkner, Founder and CEO of Epic said, “Good software is art.” To this, I would add that it is only possible to create a well designed EMR if a practicing physician is intimately involved in both design and programming of the EMR.

Now that many of my former ComChart users have had to leave ComChart EMR for one of the large commercial EMRs, I have come to realize that some of these large EMRs lack features which were in ComChart EMR and which the former ComChart physicians wished were in their new EMR. In an attempt to improve the quality of these large, commercial EMRs, I have created the below list of features which, in my opinion, should be in all /most EMRs.This list is not intended to be comprehensive and it is totally subjective. While I expect that some of the items will be in some EMRs, I am certain that they are not in all EMRs.

As this list is a bit long for a typical posting on The Health Care Blog, I will present the half of  my list below, which will include suggests regarding the Lab section and the Progress Note section of the EMR. The second posting on The Health Care Blog will discuss other suggested features for EMRs.

A Universal Truth about EMR design

It is essential that when all EMR features are incorporated into the EMR so that 1) they make their presence obvious to the user at the point moment in the clinical encounter and 2) the feature should be presented to the user in a manner which make it intuitively obvious how to utilize the feature or at least how to learn how to use the feature without being referred to a manual or told to attend a “training class” or call “technical support.”

Lab feature:

There should be button that causes the EMR to only display all the abnormal lab test results and then gives the user the ability to sort the resultant list by test name, test date or any other parameter which is available. This can be invaluable when trying to understand the etiology of a patient’s symptoms.

Lab feature:

The physician should be able to display any subset of a patient’s lab results, with the option to omit individual results, re-sort the displayed data (by date, value, name) and be able to export the data in cvs or Excel format. 

Lab feature:

It should be possible for a physician to create a chart of lab tests, on the fly, which include any combination of tests from the patient’s existing labs. It should be possible to incorporate this lab chart into a Progress Note or print out the chart for the patient.

Lab feature:

It should be easy for the physician to create an association between incoming test results (or LOINC value) and specific medicines so that when a incoming lab result is filed, the associated medication name appears alongside the file results. For example, every time a cholesterol result is filed, if the patient is on a statin, the name and dose of the statin will appear alongside the test result. In addition, this field should be accessible to the physician so they can add/alter the information as they feel is necessary. Other potentially useful associations are HBA1c and diabetic medicines, potassium and ace inhibitors, Vitamin D and ergocalciferol, etc. With this association incorporated into the lab results, it should be possible, with one click, to create lab charts which include the concurrent medication information, like this…

Lab feature:

Within the labs, it should be immediately obvious who ordered a test and to whom a copy of the test was distributed.

Progress Notes:

Physicians should be able to create a chart of any lab test results, from within the Progress Notes, by simply typing some sort of macro like “\\Lab test name.” This type of feature reduces unnecessary navigating around a patient’s chart and improves a physician’s work flow.

Progress Notes:

A physician should be able to add selected free text from the Progress Notes to either the Problem List, Medicine list, Allergy list, Family History or Old Problem list by simply highlighting the data and clicking a single button. This will reduce the need for “double entry” of data.

Progress Notes:

There should be a free text field on the Progress Note layout where a physician can enter information that is not officially part of the patient’s patient chart and will never be exported or printed. This feature would allow a physician to write note to themselves like “Daughter wants issue of her mother’s depression discussed at the mother’s next visit, and daughter does not want to be identified.” Prior to the creation of EMRs, physicians would attach a piece of paper to the outside cover of the patient’s manila folder.

Progress Notes:

The physician should be able to search all of an individual patient’s free text Progress Notes for a word or phrase. It should also be possible to search a subset (or all) of the entire EMR’s free text Progress Notes for a word or phrase. This can be very useful when doing population searches or when trying to find a particular patient whose name is unknown.

Progress Notes:

The user should be able to print out any (or all) sections of a patient chart with no more then 2-3 clicks and concurrently print out a pre-addressed envelop. The design of this process should give the user the ability to have complete freedom to decide which sections of the chart will be included in the print-out, down to the level of individual test results and Progress Notes. This can be very usefully when creating referral letters.

Progress Notes:

The physician should easily be able to create template Progress Notes without the need for an IT person. These can be constructed from a series of “macros.” Examples of Progress Note “macros” should include:

ACTUAL DATA which will appear in the Progress Note MACRO

HISTORY AND PHYSICAL h&p or H&P

Today’s date TodaysDate

Time GetCurrentTime

Patient name PatientName

Patient’s nick name GetPatientsNickname

Date of Birth GetPatientDOB

Patient age on date of office visit GetPatientAge

Problem list (comma separated list) GetProblemList

Problem list (one Dx per line) GetParagraphProblemList

Problem list (one Dx every 4th line) GetParagraph2ProblemList

Diagnosis list(comma separated list) GetDiagnosisList

Diagnosis list (one Dx per line) GetParagraphDiagnosisList

Diagnosis list (one underlined Dx every 4th line) GetParagraph2DiagnosisList

Diagnosis list with dates (one Dx per line) Get_ParaProblemListWithDates

Medicine list (comma separated list) GetMedicineList

Medicine list (one Rx per line) GetParagraphMedicineList

Old Medicine list GetOldMedicineList

Allergy list (comma separated list) GetAllergyList

Allergy list (one Rx per line) GetParagraphAllergyList

Flowsheet data (most recent) GetFlowsheetData

Flowsheet data (all) GetAllFlowsheetData

Flowsheet data past due GetPastDueFlowsheetItems

Old Problem list (comma separated list) GetOldProblemList

Old Problem list  (one Dx per line) GetParagraphOldProblemList

Family diseases (comma separated list) GetFamilyDiseases

Family diseases (one Dx per line) GetParagraphFamilyDiseases

Social history GetSocialHistory

Habits and Risk Factors GetHabits&RiskFactors

Review of Systems GetReviewOfSystems

Most recent vital signs GetMostRecentVitalSigns

Chart of vital signs (chart of all data) GetChartOfVitalSigns

Chart of vital signs from last 3 years GetChartOf3yearsVitalSigns

Saved History GetSavedHistory

Saved Physical exam GetSavedPhysicalExam

Saved ROS GetSavedROS

Saved Procedure GetSavedProcedure

Saved Treatment Plan GetSavedTreatmentPlan

Clinical Summary (Probs, Meds, Allergy, FSH, habits) GetClinicalSummary

Lab results (all) GetAllLabResults

Lab results (all) data results only GetAllLabsDataOnly

Lab results (< 12 month old) Get12mLabResults

Lab results (< 12 month old) data results only Get12mLabsDataOnly

Lab results (< 6 months old) Get6mLabResults

Lab results (< 6 month old) data results only Get6mLabsDataOnly

Lab results (< 3 months old) Get3mLabResults

Lab results (< 3 month old) data results only Get3mLabsDataOnly

Lab results (< 1 months old) Get1mLabResults

Lab results (< 1 month old) data results only Get1mLabsDataOnly

Lab results (≤ 7 days old) ) Get7dLabResults

Lab results (≤ 7 days old) data results only Get7dLabsDataOnly

Lab results (most recent labs) GetMostRecentLabResults

Lab results (most recent labs) data results only GetMostRecentLabsDataOnly

Radiology reports (Entire text of all) GetXrayReports

Most recent radiology report GetMostRecentRadiologyReport

Radiology summaries (Recent, first) GetRadiologySummaries

Radiology summaries(Oldest, first) GetChronologicRadSummaries

Most recent radiology summary GetMostRecentRadSummary

Radiology summaries < 1 month old Get1mXraySummaries

Radiology summaries < 3 months old Get3mXraySummaries

Radiology summaries < 6 months old Get6mXraySummaries

Radiology summaries < 12 months old Get12mXraySummaries

Radiology reports < 1 month old Get1mXrayReports

Radiology reports < 3 months old Get3mXrayReports

Radiology reports < 6 months old Get6mXrayReports

Radiology reports < 12 months old Get12mXrayReports

User’s name MedicalProvider

Name of Primary Care Physician PCP name

Name of Referring Physician Referring MD name

Progress Note ID number PGNIDNumber

Associated clinicians (Includes PCP & Referring MD) GetAssociatedPhysicians

Chart of patient’s CBCs LabChart:CBC

Chart of patient’s Electrolytes LabChart:Electrolytes

Chart of patient’s Lipid Profiles LabChart:LipidProfile

Chart of patient’s INRs LabChart:INRChart

Chart of patient’s Lipid Profiles LabChart:LipidProfile

Chart of patient’s Liver Function Test LabChart:LiverProfile

Chart of patient’s Thyroid Profiles LabChart:ThyroidProfile

List of diagnostic tests pending GetListOfTestsPending

List of prescriptions written today GetPrescriptionsWrittenToday

Associated billing claims information GetBillingClaimsData

Copayment of Primary Insurance GetPrimaryInsurance

Copayment of Secondary Insurance GetSecondaryInsurance

Copayment of Primary Insurance GetCopayPrimaryInsurance

Copayment of Secondary Insurance GetCopaySecondaryInsurance

Get all CPT names modifiers codes GetAllCPTNamesModifiersCodes

List of all CPT codes GetAllCPTCodes/Names

Most recent CPT code (CPT1 from last visit) GetLastCPTCode/Name

List of Diagnoses with ICD codes (one line) GetDiagnosesWithICDCodes

List of Diagnoses with ICD codes (paragraph) GetParaDiagnosesWithICDCodes

Get patient’s next appointment GetPatientsNextAppointment

Progress Notes:

The physician should be able to easily create personal “macros” where the physician types an appreciation and the EMR replaces it with the associated text information. For example;  the user might create the macro “\paoa” which when entered into the EMR’s Progress Note immediately gets replaced with “Patient aware of above”.  Or the physician might create a macro “\gcl” which is immediately replaced by

“PAST MEDICAL HISTORY:

PROBLEM LIST:

GetParagraphProblemList

MEDICINE LIST:

GetParagraphMedicineList

ALLERGY LIST:

GetAllergyList

RISK FACTORS:

GetHabits&RiskFactors

SOCIAL HISTORY

GetSocialHistory

FAMILY HISTORY:

GetFamilyDiseases

PHYSICAL EXAM:

GetVitalSigns”

And then, the “standard” macros (like GetParagraphProblemList) get replaced with the actual patient data. All of this will make it easier for the physician to minimize the time they spend “charting” and give them more time to interact with their patents.

In my next posting on The Health Care Blog, I will discuss some other features which I believe should be in all EMRs.

Feel free to add to this list. Maybe the large EMR vendor will read your suggestion and add the feature to your EMR.

Hayward Zwerling, M.D.is the founder of ComChart, a now defunct EHR program. He practices with the Lowell Diabetes and Endocrine Center.  

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Donald BugbeeTriyam_GautamMichael Chen MDHayward_ZwerlingMargalit Gur-Arie Recent comment authors
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Donald Bugbee
Member

Dr. Zwerling, do you have a wish list for mobile EHR applications?

Hayward Zwerling
Member

Sorry, no.

Triyam_Gautam
Member

One key reason for failure of new EHR implementation is failure to bring over all historical medical records to the new system. EHR vendors should make it clear to hospitals that they do not convert over all data to new systems. Hospitals by now must be aware that they need to engage professional Data management companies who can help transition all the historical clinical and clinical data into the new EHR or archive them. When a nurse is forced to lookup two different systems to get a one year old lab report of a patient, I am sure they are… Read more »

Hayward Zwerling
Member

I do not believe this is a significant problem nor is it the major reason for failures of new implementation. In fact most clinical data that’s more than 3-4 years old is usually not clinically relevant, with occasional exceptions.

Hayward Zwerling
Member
Michael Chen MD
Member
Michael Chen MD

A lot of these items have some design commonalities with my own open-source EHR that was also designed and coded by an MD (NOSH ChartingSystem); which goes to show that MD’s really have a specific way of organizing and processing medical data that the large EHR’s clearly miss the mark and they really don’t cater to our needs. For those that are big structured data supporters (and I sympathize with this) and think that these large EHR’s think they’re doing “us a favor” – here is really the crux of the problem: MD’s don’t think like structured data when it… Read more »

Hayward Zwerling
Member

The large EHRs are designed and revised by committees, dominated by IT people, who have little if any experience in the exam room or taking care of patients. They are constructed to meet Meaningful Use/Certification mandates and the needs of the institutional buyers who purchase these EHRs for their own purposes, rather than the needs of the real users of these EHRs, who are the practicing physicians and the patients.

Stay tuned for Part 2 of this essay which will contain a host of additional recommended EHR features and will post here on THCB.

Margalit Gur-Arie
Member

So, as far as I know, these things are there in many EMRs. Maybe none has absolutely all of the things on this list, but I don’t see much that has not been at the very least considered, and worst case scenario, placed on a to-do list (I don’t know that “macros” would be my preferred vehicle for implementing these things though). Another observation regarding the above is that there seems to be an intent to “drop things to paper” (or Excel). In our current (misguided) environment, such exports are a no-no. Referrals should be electronic, patient communications should be… Read more »

Hayward Zwerling
Member

The ability to move data out of an EHR (and into an Excel spreadsheet) and the “slicing and dicing” of lab data, is absolutely essential when trying to provide good medical care to the individual patient and for “population management” at the local level, i.e. in a small practice. If the data is lock in the EHR, innovation suffers and individual patients will not get the care they need. As a practicing physician, I can state categorically that if I do not have free access to the data in my EHR, it will stifle my ability to take care of… Read more »

Margalit Gur-Arie
Member

I am not going to comment on KLAS ratings or any other “ratings”, and I am certainly not going to argue about the qualities of your former EMR, which I am sure was great. The simple fact is that Mr. Slavitt and his “health system” “transformation” bonanza, put your EMR out of business. And regardless of the new and improved messaging promotion campaign, the same effort is putting independent physicians out of business all over the country, consolidating all decision making power, including EMRs, in the hands of a few people whose job description is to make money or save… Read more »

Hayward Zwerling
Member

I agree that MU, MACRA and Certified EHRs have interfered with our ability to innovate in the HIT realm and have had a very negative influence on the practice of medicine.

I think that the best thing the Federal Government could do at this point would be to:
1) ask Congress to legally end the MU/MACRA mandates that are written into the HITECH act
2) limit itself to promulgating interoperability standards
3) Formerly endorse and promote the Massachusetts Medical Society’s Seven Principles for the Responsible Implementation of Health Information Technology (https://thehealthcareblog.com/blog/2016/05/23/seven-principles-for-better-information-technology/)
4) Mandate that all EHR companies publish their source code (https://thehealthcareblog.com/blog/2015/11/02/a-proposal-to-increase-the-transparency-and-quality-of-electronic-health-records/)