I 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.”
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.
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.
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.
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…
Within the labs, it should be immediately obvious who ordered a test and to whom a copy of the test was distributed.
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.
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.
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.
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.
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.
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
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
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:
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.
Dr. Zwerling, do you have a wish list for mobile EHR applications?
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 not a happy customer! Check more for successful EHR implementation on
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.
Part 2 of this list is here…
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 comes to clinical decision making and workflows. Any attempt to do so is going to feel like stuffing a square into a circular hole. When we see things in a old-fashioned paper chart – we see things in timelines as if it is like a current Twitter feed (that’s the closest modern analogy). And like a Twitter feed, we want key snippets that also capture the non-structured data stuff – particulars about the patient that are unique (here’s the “art” in the art of medicine). All these EPIC patient encounter reports are sanitized gobbledygook that don’t translate to anything really “meaningful” to docs like us.
And so, to bridge this non-structured and structured divide really comes down to a maturation of a Natural Language Processing engine – and it needs to run nearly in real time in conjunction with an MD inputting these clinical “tweets”. So what the MD sees are the tweets, unsanitized and full of rich history but in the background, structured data is curated and stored for research and analytics as well as for communications to other physicians and organizations.
That’s the future, in my view, and that’s where my open source project is aiming towards. In the meantime, the struggle continues…
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.
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 electronic, etc., and most importantly structured data This of course serves no clinical purpose, but EMRs have a very different purpose, and I am not referring to billing here.
One last note regarding the copious slicing and dicing of lab results. I have yet to see anybody use or attempt to use all those features. Yes, I know, everybody asks for “trending” and such, but rarely do you have time to engage in anything more than glancing at a flow sheet, and in my experience, not even that.
I don’t think a “good” EMR necessitates that physicians engage in architecture and design, let alone actual coding. I do however think that those who design EMRs should have an intimate knowledge of actual medical practice. And I also would like to point out that what one physician thinks is the best thing since sliced bread, may very well be considered wasteful, clunky and completely unnecessary by other physicians, and vice versa.
Building software is an art form, the art being that of elegant consensus building through fair and informed compromise. Unfortunately, most EMR design is now in the hands of powerful (political) people who know nothing, want to learn nothing, and have nothing but deep disdain for physicians, their opinions and the way they practice medicine. Ergo, doctors will not change how EMRs are built, but EMRs will change how doctors practice medicine (if you can even call that medicine…).
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 my patients. The EHR should make the data accessible to the physician user so the physician can take care of their patients in the manner they deem best. An example of what can happen when the physician can easily get the data out of the EHR and into Excel can be seen here… https://thehealthcareblog.com/blog/2015/10/10/cool-stuff-i-taught-my-ehr-to-do/
Whether or not features listed above (an in Part 2 of this essay) are on the EHR vendor’s “to do list” is unknown to me. The problem is the vendors are spending all their resources meeting Federal mandates, rather than spending the resources on meeting the needs of the actual clients (the practicing physicians and the patients.)
In regard to the statement “what one physician thinks is the best thing since sliced bread, may very well be considered wasteful, clunky and completely unnecessary by other physicians” may or may not be true. However, the only objective assessment of an EHR’s utility to the practicing physician is the KLAS ratings. There were few if any EHRs whose KLAS’s ratings exceeded my EMR’s KLAS ratings.
Finally regarding your statement “doctors will not change how EMRs are built, but EMRs will change how doctors practice medicine” shows a misunderstanding about our healthcare system. The only people who have the potential to improve the quality of the healthcare are those who practice medicine. Health information technology is probably not “the solution” to our healthcare system, but, properly designed HIT tools may enable physicians to redesign the healthcare system so it works better for everybody. I think that is the message that Slavitt (and others) are now promoting…ie It is time of the physicians to take control of the HIT tools and use these tools to build a sustainable, equitable and efficient healthcare system.
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 money by any means necessary.
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/)
Wow. It is shocking that some of this stuff is NOT available.
This is basic, basic, basic.
I’d love to see Andy Slavitt’s list, I have a feeling a lot of these would be on it. ; )