HealthBlog

Dr Crounse,

I remember reading something about Virginia Mason successfully implementing the Toyota process to some quality initiatives a few years ago; further proof that these concepts can be applied to healthcare.

As a former practicing clinician, I agree with you that MD's/RN's and ancillary support staff fear wasting time, however, I wonder if this is a symptom of our fee-for-service healthcare finance model.

You make a very valid point; for providers, you can't have "meaningful use" without the word "use" (any EMR/EHR has to be easy to implement and adopt) and from a consumer perspective, it's not about  "meaningful use" at all but about "meaningful results"

Dr Crounse,

I agree with your assessment that an electronic medical record (EMR) solution needs to fit seamlessly into workflow. To this I’d like to add several other observations gained through personal experience using an EMR. While my experience is with the military’s Armed Forces Health Longitudinal Technology Application, AHLTA, I believe they hold true under any EMR design.

One size does not fit all – Each specialty has unique requirements for medical documentation and information viewing. The design of any system should begin with this premise, not have it discovered later. How information is displayed on the screen, how images are displayed and stored, how quickly certain items are retrieved for viewing and what items should always be displayed needs to be determined at the outset otherwise usability suffers.

Easy as paper (or easier!) – I realize that many of us do not rely solely on paper records at this point, but whatever EMR solution is developed a goal for designers should be that it is at least as easy to use as paper. I’d like to say ‘easier than paper’ however I think ‘at least as easy as’ is a difficult enough goal to reach. If it is as easy as paper then the other benefits of an EMR are enhanced and this becomes the tipping point for acceptance. Importantly I don’t say better than paper. Better to a designer may not be better to a user. Easier on the other hand saves me time and helps me do my job documenting more quickly and efficiently so that I can focus on the important aspect of medicine, which is taking care of patients.

Accuracy – clearly this is expected in any form of medical documentation. However, it is not as simple as moving from paper to digital. Particularly in a large organization, with numerous medical specialties, lab functions, and administrative components (to name only a few) spanning multiple regions, the complexity can reach a level that unintended consequences become almost assured. Designers need t o understand from the outset that if accuracy is not assured users will lose confidence in the system and be reluctant to use it.

An EMR should be an EMR – A system that automatically documents work hours or tracks inpatient hospital days is useful, but it isn’t an EMR. Those and others metrics are important to measure, but they are not about documenting medical care. Let the EMR be focused on efficiently documenting patient care and have other systems for other things.

I don’t think we are there yet, whether it is with the system I use, AHLTA, or with other systems I’ve seen elsewhere. I realize the challenges involved in designing and developing an effective EMR. I also believe that the promise held in EMRs is great and worth the time and effort to get it right.

Michael Mines, MD

Lt. Colonel, Medical Corps,

US Army

Dr. Crounse -

Thanks for your very intriguing assessment of the dynamics that go into physicians, prescribers and also, consumers, accepting the use of eletronic medical records. It's interesting that you point out that just because we have all of these great new forms of technology at our disposal, that doesn't necessarily mean they are fixing a problem or expediting certain processes. In many cases, either the barrier to entry is too great for some to adopt, or the cost is too prohibitive for many smaller offices/practices to take on.

I'm curious about your opinion on how the healthcare industry will manage the continual onslaught of technology with the needs of physicians, prescribers, consumers, PBMs, etc., to faciliate more safe and secure practices? What steps does the industry, as a whole, need to take to ensure that the best types of technology are adopted on a broad basis, given what you have described in your post?

@KeithTrivitt

Dr Crounse,

I read your article with interest.  I work for the NHS in the UK (so not in a fee-for-service system) and clinicians here have similar fears.  Although I personally am a huge supporter of innovation, I too have my doubts and echo the views expressed by Dr Mines.  I think this stems from experience of too many poorly thought out systems which were introduced by managers without thought for the clinicians using them and their specific needs.

I work in Emergency Medicine, and it is a constant frustration not to have an electronic patient record to refer to when a patient comes through the door and has an extensive past history.  However, I don't want to see our staff time and efforts wasted on a system which is unhelpful and cumbersome to use for the sake of modernisation and computerisation.  In this sense, the paper record "does the job".

I agree that until there is something out there that represents a significant improvement on this, that does the job the clinicians need it to do (and in less time!) and is intuitive to learn and use that we should not "throw the baby out with the bath water" in the name of "advance".

I am sure that I am not the only one who will need more convincing at this time.

Dr Serena Ayers

Consultant in Emergency Medicine, London

Interesting and appropriate comments so far. Having operated an electronic medical office for over 7 years, I can safely say that most of physicians' fears about conversion to EMR-based practice are actually justified. I was able to do what I did because we started from scratch and had very little conversion.

If one can imagine, it is like trying to change tires while still driving the vehicle - not possible. Apart from this, the tremendous resistance from other players such as laboratories, hospitals, etc. Besides, while we all can appreciate what Toyota has done for cars, medical care is far from assembly line processing. In fact, my effort at using IT in practice has actually been to get rid of an assembly line type process, and reintroduce meaningful interaction between patient and clinician.

The other (major) factor to blame is the CPT system, which has forced everybody to conform to codes rather than to clinical standards. This has also forced IT companies to design systems to comply with CPT codes, rather than improving efficiency. The glaring omission I see is that IT companies have not utilized the expertise of clinicians in the trenches to build/improve systems that can actually work in clinical medicine. The system in WA that you refer to can only work in that environment, and provides care to a very tiny segment of the population.

[...]The first image on this blog post really sums it up: [...]

Interesting argument..

Recently I had written a research piece on Innovation and it's true that it happens when learnings cross different paradigms. Successful people and organisations either 'do different things' or 'do things differently'. Disney and Toyota are classic examples from past..

I was also going through a report on Computer Based Patient Records, released in 1990s and those researchers had divided themselves into various groups. One of the group was called "Users and Uses subcomittee". Your argument falls in the same group. Evaluation of technology from Sociological perspective is the key to thinking..Technically it has been called 'Deconstructing the Black-Box'.

At this point I would also constructively say that obduracy may hinder a user to adopt new technology, but a NUDGE can be given to change the habits (http://books.google.co.uk/books?id=dSJQn8egXvUC&dq=nudge&client=firefox-a). It will help in "generating good number of options without restrictions" for HCPs and HCOs. Results can speak for themselves! So far I've seen remarkable results with EMR, but more are in pipeline. I would cunningly say- if few are not using it, many of them are..In a long run the cost of not adopting EMR could be costlier than taking up an existing solution.

My Editorial on the State of the Electronic Record.

In my opinion 90% of the code currently written for EMR/EHR’s is worthless.  It consists of useless bells and whistles for marketing or provides solutions to problems that simple don’t continue to be a problem when you adopt an electronic record.  The remainder of the useless code is the myriad workarounds that are crafted to make a poorly designed product work.

90% of what doctors write in the paper chart is NOT for the benefit of the patient but is to support the billing being generated or to protect the Doctor from the claimants attorney.  Only 10% is useful, valid medical facts.

So we find ourselves looking at very expensive complex systems designed to improve 90% of the 90% we shouldn’t even be concerned with in the first place.

In the late 1960’s Lawrence Weed, in his landmark work, “The Problem Oriented Medical Record” gave us the template of a proper Electronic Record.  He will always be remembered for helping us move from the prose medical note to the S.O.A.P. format that most doctors today are accustomed to.  But in his book, nearly 40 years ago, he offered the plan to be used for the Electronic Medical or Health Record.  The power of the computer was NOT to be wasted on billing and coding.  The medical data base should help the Doctor practice medicine.  Weed envisioned a system which would recognize symptoms, and clusters of symptoms which were highly predictive of certain disease states.  The computer should recognize the tests being ordered, or the diagnosis being coded and anticipate if you need help with the differential diagnosis.  Then, when it is appropriate it should prompt you with suggestions for disease to consider, and the relative likelihood of a correct diagnosis, (from horses to zebras).  It should offer the correct tests to be ordered, and it should be able to offer the best clinical practices when the Dr. wants help.   And yes it should recognize outliers when to do so will IMPROVE the quality of care, not just improve the statistics.  Don’t waste my time telling me I have one of the sickest patients ever, unless you can offer me some suggestions that might help make the patient better.  

We have a small EMR that is doing a good job for what it was designed for, but it is far short of the vision of Larry Weed, and it is far short of the needs of the American People.