My Ideal EHR

flying cadeuciiGive me technology which improves my life and that of my patients, or give me death.  Medical records must be informative, efficient, and flexible; like the physicians they serve.  For me, a medical record does not contain just a collection of problem lists, prescribed medications, and immunizations; it is a noteworthy account of the health care provided to another human being over a lifetime.

Recently, I attended a baby shower of a patient who is now an adult.  (I am a pediatrician.) I brought her medical chart wrapped with a satin bow as one of her gifts.  I was her physician for many years; my father had taken care of both her and her mother as children.  Her growth, development, immunizations, and illnesses were all recorded; but so were 25 years of life experiences, trials, triumphs, and tribulations.  The back section contains drawings she had given me, newspaper articles of her achievements, graduation announcements, and her wedding invitation.  Obviously, medical records register growth parameters, vital signs, and sick visits; but they also encompass my relationship with my patients.

New technology must be better than what I already use; otherwise there is no reason to change.  In 2009, the Department of Health and Human Services led many to believe (incorrectly) “using electronic health records will reduce administrative burdens, cut costs, reduce medical errors and most importantly, improve the quality of care.”  Few, if any, of these goals have materialized.  IT experts are tinkering with the grand design of a documentation method that has satisfactorily served physicians for hundreds, if not thousands, of years.  It is no small undertaking; a certain degree of diligence is required for conversion to experience success.

Administrators, MBA’s, and CEO’s know nothing of providing patient care, yet they spend obscene amounts of money on fancy automated systems which are grossly incompetent at facilitating our workflow.  Electronically generated notes take up to six faxed pages instead of the requisite one, yet provide little in the way of useful information.   How is that an improvement on what we had before?  Non-physician health leaders are missing the forest for the trees as they search for innovative ways to enhance data collection while overlooking the accumulation of critical information to support proper medical decision making.

Electronic records need to be user friendly, free or low cost for physicians, and reduce the workload, but current systems are far too cumbersome to accomplish this task.  The more complicated and structured the program; the less likely it appears to improve patient care while increasing the physician burden at the same time. Few primary care physicians have weighed in on technology needs because we are busy seeing 20-40 patients per day.   We do not need computers to do the thinking; we need them to do the documenting with speed and accuracy.

To improve care quality, adaptability is also imperative in any electronic system.   Using a simple, basic, and more customizable interface would allow each specialty to tailor the structure to fit their individualized needs.    Clicking pre-defined boxes on a computer screen does not capture the essence of each patient nor adequately describe the distinctive features of various medical conditions.

Visually, my ideal EHR would be a “paper chart” on a computer screen.  The first page would be a standard intake form providing the general health background, birth history, past medical and surgical histories, allergies, immunizations, medication list, and pertinent family history.  The second page is the problem list and other necessary details depending on medical specialty.  The third and fourth pages would be growth charts and then the immunization record follows.  Those pages could be accessible by tabs on the left hand side of the screen to review or update when necessary.

Pressing the edge of the screen would allow review of previous notes with one touch.   There would be tabs on that right side to review labs, radiology reports, and “one-page” notes from consulting physicians with the impression and plan succinctly summarized at the top.  The last tab in the bottom right corner of the screen would contain scanned newspaper articles, pictures, notes, and cards from my patients; I call that my “friendship” section. It is a “custom” add-on that should be offered to primary care physicians like me.

The structure for each note would be SOAP in format; it would take 60 seconds to record an office visit by dictation. A program would convert the dictation to a word processing document in the SOAP layout.   Auto-fill would be unnecessary with such a swift and efficient system.  It must be resistant to crashing and have an auxiliary back-up to store new notes if glitches arise so as not to negatively impact patient care.  Our office has been open during earthquakes, a flash flood, when the power is out, in a windstorm, and when there is snow, sleet or hail (just like the post office.)  Our paper records have never been inaccessible or unusable.

Do not forget the fundamental purpose of medical records in the first place.  They are a chronicle of diagnoses, treatments, and follow up for myriad of medical conditions. Systems attempting to be “one size fits all” lead to over collection of redundant information in the name of comprehensiveness. Unfortunately, no single system has yet achieved the Holy Grail of being cheap, efficient, and accessible while improving the quality of patient care.  Only technology that enhances the practice of medicine for physicians should make the final cut.

It is vital that new technology benefits both patients and physicians, enriching our non-judgmental, empathetic, and long-term relationships.   Seven years ago, I lost a college-aged patient in a car accident.  Placing the final dictation in her chart a week later gave me the opportunity to reflect on our relationship and her assorted illnesses, injuries, and well visits over almost two decades.  What a treasure to behold after years of friendship and medical care.  Her paper chart was tangible proof of a life well-lived.

I recently contacted her mother to inquire if she wanted her daughters’ medical chart.  She said it was a gift to see her daughter through the eyes of her physician, who was there every step of the way.  Medical records are more than metadata on a computer screen; they are a sacred chronicle of our enduring connection with our patients in life, and even in death.   When an EMR can do that, I will be thrilled to embark on a digital journey.  Until then, give me paper or give me death.

Niran Al-Agba, MD is a pediatrician in private practice in Washington State.

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19 replies »

  1. Forty features which should be in most EHRs:

    I also think that one way to improve EHRs is to ensure they contain no errors or bias. I had talked about this previously (, and gave a presentation at the IHT2 Conference Nashville (8/12/16) entitled: A Proposal to Increase the Transparency and Quality of Electronic Health Records

    A copy of the slide presentation is available here …

    Hayward Zwerling

  2. Aptly stated. I began writing my own EHR years ago in MS Access. I rewrote it in Filemaker a few years ago. It does everything both you and I want an EHR to do. Sadly, my work was for nothing thanks to Obama and his Meaningful Use zealots. Now, why would I want to use someone else’s politically correct EHR – cluttered up with useless government-mandated questions – that works against my method of working with patients? If I have to, I’ll happily go back to paper. I’m not a millennial wimp. I can live without air conditioning, cell phones, computers, internet, Twitter, Starbucks and cable television. I can even live without color TV. In fact, I’ve lived it. Paper is no problem for me.

    • That is what I am saying. Until something better comes along, (which could still happen) paper is the most cost-effective and efficient way. If we went back for a little bit, maybe IT would get their rears in gear and provide something more enticing to make the switch!

  3. Dr Al-Agba,
    Your concerns and requests will be documented in my open source EHR project, NOSH ChartingSystem. ( As a fellow family physician (who also practices in Washington and Oregon, “Hello neighbor!”) who happens to also code; I also firmly believe we need a new system. Like Dr. Carter alluded to, we will need to radically transform the design of the EHR and I’ve thrown the first stones with my open source project to see how we as physicians can redesign EHRs to benefit us and our patients (and leave the middleman out). What William Palmer alluded to, it’s about who has the control (right now, I don’t think any physician feels we have control over our EHR/documentation destinies).

    Being open source, it leads to lower costs since you’re not paying the licensing fees that are a feature of all of the proprietary systems that have been forced upon us through MU.

    Being open source, it allows us physicians to peer review the design and functionality of our system instead of something behind the curtain and not know how or why something works the way it does (or more aptly, not work for us).

    Being open source, it allows for true innovation since NOSH is embarking on a revolutionary project that could address the interoperability problem through a novel concept called the patient centric EHR ( We don’t lose control as physicians in this type of scenario since the relationship between patient and physician in this arrangement allows physicians to still have the choice to use their own EHRs or have their own, or use what the patient presents (which is essentially the same as NOSH, except the patient owns and controls their own instance). Since it is web based, anyone that the patient gives permission to will be able to access and edit their ongoing medical record, just like what you envision a medical history should be…not a fragmented mess from one institution/provider to another.

    Great post!

    • Dr Chen – thank you. I clicked your open source link… I don’t exactly understand what I am looking at. Is this in development and there will be an end product designed by docs?

      • What you’re seeing is my project page where the source code is stored. The link I gave is a running list of “issues” that is a repository for feature suggestions, bugs, etc. If you want to know generally what my project is and where it’s going you can use this link which is a Wiki for my project and my blog which talks about why I created this project. In the blog, you’ll see a link for a fully functioning demo to see what it can already do ( It is already an end product and highly usable (doctors are using it in their own offices) and it’s updated regularly. Yes, you can download it for free and use it however you want, and I get no compensation for it, but, like I said, I want this to be a starting point to design an provider/patient centric EHR.

        • I think you are a doctor after my own heart… so to speak. I will look at it. Thank you! I do believe it will ultimately be the “free” and adaptable system that will win out!

      • Progress starts with coming to terms with what we want clinical care systems to do. EHR systems were designed to be charting systems. However, as every clinician knows, patient care consists of many more activities than writing notes and looking up information in charts. More sophisticated information management functions—care coordination, results management, patient engagement—require systems that go far beyond “chart-centric” designs. With this in mind, what is needed most right now is a much deeper understanding of what clinicians do every day.

        MU has caused problems, but it has also provided the benefit of making clinicians aware of how critical their input is to good system designs. As this awareness has increased, documents such as the consensus statement on EHR functionality released by American Academy of Family Physicians, American Academy of Pediatrics, American Board of Family Medicine, and the North American Primary Care Research Group (Electronic health record functionality needed to better support primary care,

        Input and ideas from clinicians – your post is a good example – are also necessary to create a set of requirements that can then be turned into working systems. Ten years ago, such input was quite rare. Hayward Zwerling has written quite a bit on this topic as well (

        Aside from clinician input, experimentation with new technologies is required. Ten years ago, relational databases were the norm for all data storage. However, healthcare has many types of data, so forcing everything into a relational format is not the best design thinking. I am very encouraged by the maturation of graph databases as potential health data management tools. Finally, clinical care consists of processes, so some type of process management capability is desirable in systems that support clinicians in their work. Fortunately, as with graph databases, workflow technology has matured rapidly over the last decade, and now robust cloud-based, workflow systems with iOS/Android app support are available. Much better clinical care systems are possible.

        For anyone interested, I am trying to create a repository of design suggestions. Suggestions for improving EHR systems are welcome—everything from little annoyances to “wildest dreams.” If interested, please submit design/feature suggestions using this contact form (

  4. Dr Al-Agba,
    Many clinicians share your concerns. EHR systems, as currently designed, are indeed often more cumbersome versions of their paper cousins (see Is the Electronic Health Record Defunct? Better systems are possible, but not without a radical change in design thinking.

    The tools and technologies required to produce the type of system you describe already exist (see Why I Am Still Optimistic About the Future of HIT However, the system you long for requires an architecture that is radically different from current EHR systems. As a result, current vendors would have to completely abandon their current system designs to produce what you seek. But who knows, something better may be just around the corner…
    (BTW, like your blog!)

    • Thank you for reading! So how do we get started on this radically different architecture? Current vendors should abandon their current designs especially if they are not effective or efficient. How do dissatisfied, paper-loving, primary care docs find the system we seek?

    • Thanks for helping to spread the word about better approaches to EHR design and workflow!

  5. The EHR vs the paper chart could be easily looked at scientifically so we don’t have to guess as to its value: total bits of information; total useful information; cost benefit efficiency of information access; cost benefit efficiency of information input; scrapbook function of EHR (newspaper clippings; patient-donated foreign bodies, etc); amount of un-written information (heavy writing, light writing, capitalization, size of writing,…); accuracy of information; security and hackability; permanence and volatility of record.

    In other words, there is no reason not to study it as a tool in information handling, just as we would look at transmission to a satellite.

    The fact that none of this is being done is because there must be other more, or as powerful reasons for the push for EHRs–besides their questionable utility in medical care: information flow to governments; insurers and payers; hospitals; policy makers; legislatures….; professional discipline; labor utilization….

    • Dr. Palmer, “information flow to governments; insurers and payers; hospitals; policy makers; legislatures….; professional discipline; labor utilization….” You have hit the proverbial nail on the head! Wanted to mention in the name of efficiency, I keep all the foreign bodies (after cleaning) with labels including date and patient name on the wall in my office. I never thought about putting them in the chart, but that is yet another benefit of paper 😉

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