This is part 3 of a 3-part series: EMR 101.

Along with Step 4, Step 5 starts to open the door into EMR 201: Getting Really Good.

If EMR 101 is about surviving the day, EMR 201 is about getting efficient, which enables you to think widely and deeply about patient care, as well as proactively.

Step 5a: Abstract

Abstracting refers to distilling old chart or patient record info directly into your EMR. It differs from scanning those other records, in the same way that data is different from information – one is raw potential, the other is immediately useful.

• A scanned chart, or hospital discharge summary, is just a snapshot, an image in your medical record reference files. It can be accessed and read, and key info extracted, but until someone actively accesses, reads, and extracts that information, it stays “hidden” in that stored picture.
• An abstracted record, on the other hand, has those key elements already extracted and transferred into your EMR where it can be quickly accessed.

More important than speed, that abstracted information can spring into action in your electronic medical record.

“Will no one rid me of this meddlesome transcription?”

So the date of  a colonoscopy report can trigger an alert when the patient’s next one is due. The date of a flu shot can trigger a reminder to give them another one this winter.

Abstracting jump starts a patient’s chart; without it, you’re missing critical information you need to treat patients on the spot. The key is to streamline that initial process.

Preferably, without you being the one doing it all, especially during the first patient visit when you should be focusing on other matters.

Step 5b: Delegate

Ideally, the electronic chart should be ready for you from the very moment you “open” it during your first patient contact.

Yeah, right.

A physician often ends up being the one inputing the “critical info set”:

• meds
• allergies
• dates of certain past tests
• diagnostic codes corresponding to diagnoses for the chronic conditions list

This results in the most accurate carryover, but at a high cost. Abstraction at this point is little more than transcribing — words from paper column A, entered into data field B. If you’re doing this regularly, congratulations on being one of the most highly paid and frustrated typists on earth.

Get good at entering the diagnosis codes, especially, and remember: this is temporary.

Delegation rears its screaming head, here — “Will no one rid me of this meddlesome transcription?” — but it actually starts long before. If your data source is legible, like from a typed hospital discharge note or a clear-clear chart summary sheet, you’re in luck. It’s possible to assign office staff (or hire personnel) to do the transfer, as closely as the day before the patient visit.

If your data is illegible, like your own handwritten notes (or where the critical data is scattered throughout), you’ve got to suck it up, plain and simple.

Get good at entering the diagnosis codes, especially, and remember: this is temporary. As the patient visits increase, the visits themselves build the necessary context for future judgments.

As long as you’re accepting new patients, the abstracting and delegating will never entirely disappear. To keep it manageable — and guard against imported data that you haven’t approved — consider the following physician/staff workflow:

1. Never allow records to be scanned without you signing off on them. The last thing you want is a damning piece of buried data that you will be responsible for, that you never saw, except at deposition.
2. Keep an inbox for documents from elsewhere, and using the previously mentioned batch processing method, work through it steadily at set times of the day.
3. Have a highlighter, or better yet, sticky pad labels (the kind that mark forms where you have to sign?), and mark the info bits you want your staff to enter into the chart, such as
   • entire EKG’s
   • dates of colonoscopies, mammograms, Pap smears, vaccines
   • any other “stick pin” items you must track or update over time
4. Pass the documents to staff in an outbox, to enter just the choice highlighted bits, then off to the general scan pile.

This way, you are not being bogged down with abstracting, your staff isn’t having to wade through and interpret an entire note for the few bits of interest, and nothing gets scanned without being cleared, first.

The next to last step to work on, on your march towards EMR mastery:

Step 4: The 80/20 Rule

Also known as “The Pareto Principle,” the 80/20 Rule is extraordinarily useful. It’s a principle of economics and management, and is most often cited today by entrepreneurs (like Tim Ferris) needing to keep vast amounts of data and responsibilities manageable. Sound familiar?

At the EMR 101 level, the 80/20 Rule goes like this:

• the vast majority of your daily patient encounters occur around a handful of clinical diagnoses

which translates into

• the vast majority of your daily documentation can be done with a handful of templates or pages.

This was alluded to in the last post, under Step 2: Get Familiar With TWO Workflows, Tops. You can go far with this one; long after you’ve graduated to speedier, more specific templates, you’ll still be able to fall back to your “old faithful” workflows whenever confronted with a condition laying outside of what your EMR was designed to handle.

But this principle extends way beyond this:

• 80% of your headaches come from 20% of your patients
• 80% of your office income comes from 20% of your health plans
• 80% of your inbound calls are about the same 20% of daily tasks (e.g. refill requests and lab reviews)
• 80% of your going home late comes from 20% of your documenting habits (e.g. doing crib notes, then going back later to reconstruct the full notes)
• and so on

Once you start seeing these trends, you can start to prioritize where to direct your attention most efficiently. In medicine, of course, you’re trying to encompass 100% as your goal; the 80/20 Rule is NOT about letting 20% of your work go undone, or missing the critical diagnosis 20% of the time!

But if you’re swimming in a morass of seemingly undifferentiated tasks, this rule can identify what to fix first to give yourself the most breathing room. Make 2 or 3 changes that lift the “crush” of your workload off of your back, and you will be much less worn down.

And “much less burnt out” means “less likely to miss critical things.”

Take That Step, You Can Do It

Think about it: take a bit of time now — when you’re floundering, I know — to regain yourself heaps of time from now on.

Push back from your desk and find a handful of problems to fix — pick 2 to start with. I’ve had great success with the following, which ultimately enabled me to end my workdays about an hour earlier than before:

1. batch processing lab reviews or med refills for 15 minutes at noon, and 15 minutes at the end of the day (instead of sprinkled throughout the day — barring any urgent values, of course)
2. finishing notes as you go, and getting rid of the “crib notes/reassemble later” habit

See how much time and energy you get back with just those changes. Then look again, find some more “big bang for your buck” issues, and go at it again.

Reclaim your day, one swipe at a time.

Next time: EMR 101, Part 3 – The Final Chapter

Did You Know? from Amybeth on Vimeo.

Once in a while, there’ll be an info source that seems to have nothing to do with EMR’s, but is so mind-blowing and actually related that it must be acknowledged.

Hence: Did You Know?

Why Do YOU Need To Know This?

Because you need to pat yourself on the back — any chance you get — about why getting into EMR’s was a Good Idea.

As the video and this other one point out: because without moves like getting on board with electronic medical records, the World…

Will…

Leave you in the dust.

Special thanks to Brandon Betancourt, of Pediatric, Inc., for bringing this video to light.

I’ve seen it in a variety of practices, my own being no exception.

Free texting to document a patient encounter.

You’ve got your clickers, the orientation spiel goes, and ya got your typers.

Me, I’m a typer, but the system allows you to document any way you like. To each his own, and I love the look of my own text!

So, when your IT folks suggest that you align yourself with the clicker column, so to speak, you might find yourself getting a mite…testy. Vocally belligerent, even — it’s a free country, and I’ll free text, doggone it.

What follows are some thoughts about why you might want to reconsider. Reeeally reconsider…

“Join Or Die”

America’s first political cartoonist, Benjamin Franklin, penned the following image, encouraging the colonies to pull together, during the French and Indian War:

A bit ominous, granted, but you get the drift. United we stand, divided we fall. And if you’re curious, the officially sanctioned “EMR cause” to join these days is discrete data entry — button clicking.

Free texting is that squirrelly separatist inclination that weakens everyone, in the face of hostile forces. Which makes sense from a strategic perspective: everyone proudly doing their own thing with a disdain for documenting consistency, can’t be good from a unity standpoint.

But in this case, the enemy isn’t France and its agents on the 18th century frontier — and if you want to text freely, the enemy isn’t your EMR vendor, either.

It’d be easier for them to make an EMR into a big, free-text machine (they’re called “word processors”), and infinitely harder to make it into the interlocking databases that true EMR’s are. Keeping track of button clicks and cross referencing list choices must be planned out in advance, with tons of user input and testing. If it’d get the job done, EMR vendors would be ecstatic at doing away with all that data juggling, and letting doctors type, cut, copy, and paste on blank screens.

Collectively, the “enemy” of free texting your entire note is any and all forces that make discrete data tracking a necessity. I’ll come back to that in a bit, but for now, remember:

Lesson #1: There’s a wolf at the door, and much as we’d like to blame the establishment, it’s NOT the EMR vendor.

So Big Vendor’s Our Friend, Eh?

You’d better believe it.

Keep in mind that any business, especially a moderately big one, will prefer to keep its internal processes simple, and its customers happy.

In EMR Vendorland, the current trend is towards button clicks and list choices, despite the fact that

1. doing so involves much more programming complexity, and
2. loads of physicians, especially from small groups or solo provider offices, want free texting

Better yet, this same group loves text macros — small programs that can run in parallel with EMR software, enabling sentences or paragraphs of a doctor’s own text to be recalled and inserted with a few keystrokes.

So are EMR vendors purposefully peeing into the wind? Doubtful, or they won’t be around for long.

Lesson #2: The EMR vendor wants to keep you a happy, faithful customer; there’s a reason for the apparent paradox in not recommending free text, everywhere for ever and ever, amen.

So What’s More Important Than Market Share?

And quite a slice of the marketing pie it is.

According to the National Ambulatory Medical Care Survey in 2003, 38.5% of physician practices are solo practices, with 73.1% of all patient visits occurring to doctors offices with 4 or fewer providers — and more than half of those visits are to solo practitioners’ offices.

And pardon me for saying so, but there’s a certain correlation between small/solo practices and wanting to document freely. You can’t make it in a small private practice without singing “My Way” in the shower all through med school.

Put 2 and 2 together, and you’ve got a lot doctors and patient visits potentially leaning towards the free texting movement. As in, “2 out of 5″ practices, and “7 out of 10 patient visits.”

If EMR vendors aren’t aware of this math, and are deliberately pissing off folk who may prefer documenting their own way, that’s a pretty suicidal business strategy.

UNLESS…there’s something more detrimental to the vendors’ future than pissy small or solo group customers.

Lesson #3: If the healthcare system itself tanks, we’re all going down.

“I’ll Kill You Later”

I’ve alluded to better and brighter minds than mine in a previous post. Apparently, the new Health & Human Services Secretary, Tom Daschle, and President-elect Obama are among them: EMR’s are figuring universally in any major plan to fix the American Health Care system.

My understanding of this is evolving, but in a nutshell, whether fatally broken or just really badly in need of repair, you need accountability to have a hope in heck of fixing the system. Meaning, track what is going where, how much it costs, what your outcomes are, and how long it takes you to get there. Get a baseline, tweak, reassess, and repeat.

THAT’s the basic, iterative mechanism that is coming (and It Cometh On Like Gangbusters):

• What’s your specialty’s average “score” at treating Condition X?
• How does your particular practice measure up?
• What are your competitors’ scores?
• How do they compare on cost?
• How do they compare on convenience?
• Why should patients come to you if your overall measures are lower?

You see where this is heading?

Re-rank the following, in order of overall significance:

• Survival of the entire healthcare system
• Survival of your practice within it
• Your insistence that “ctrl-U” spits forth your personal Urinary Tract Infection protocol on the progress note

Lesson #4: Time to get our heads out of the sand — we can argue documenting convenience later, but we will need stats and numbers to fight with real soon. For the survival of our practices, as well as the system, itself.

Youcandoitthehardway…

Or you. Can. Do. It. The. Easy. Way.

Believe me, you’ll want to do it the easy way, because “it” is going to mean combing through the data of your practice, your region, maybe even your specialty, not just for one medical outcome, but many, and not just once, but periodically, on demand, as your practice and patient demographic changes.

Again, this is the Iceman that is coming. THIS is the wolf at the door: assessing, improving, and justifying your practice’s data. It won’t matter whether it’s for your medical director, your IPA, an insurance carrier, or a government agency — data mining is as inexorable as an avalanche, and as such, you don’t argue with it, you just deal with it.

Free text strings are gobbledygook to computers. The most beautifully worded, stylistically perfect text paragraph is just one long ream of alphanumeric characters to a computer. Meaningless, so far as data mining goes, like a string of Attic Greek characters with no spaces in between.

That’s nonsense, you say, I can run a search on my text heavy records, by specifying a search string! I always use “A1c” when referring to my diabetics’ glycohemoglobin, and I always put it in field 271 on the progress note! Don’t tell me my EMR can’t accommodate my particular free texting when it comes to running reports on my diabetics!

That’s great, really it is.

What about your partner? Or your other local colleagues, or your group as a whole? Are all of them using “A1c,” or or some of them using “HbA1c,” or “a1C?” Maybe some of them put the value in field 271, but others don’t enter it at all, it’s entered automatically into the lab module via a lab interface, on page 2, field 37(b).

Your report generating strategy takes a geometric leap upwards in complexity, the minute you step out of your own practice. Why can’t different EMR’s consistently talk to one another? Sheesh, why can’t individual doctors document in the same way?

It’s Like The Jim Croce Song

Listen to a copy, if you can find one; it’s a cutie:

You don’t tug on Superman’s cape.

You don’t spit…into the wind.

You don’t pull…the mask off the old Lone Ranger,

And you don’t mess around with Jim.

Lord knows, solo and small group providers fight the good fight, every day. And not all such doctors resist “documenting digitally,” as I put it, i.e. with discrete data clicks.

But as anyone in the industry knows, it’s a recurrent phenomenon, and a recurrent refrain:

I want to document in the free text blank spaces, I want to copy and paste previous just-so notes, and I want to do so everywhere — history, exam, plan, all at once, preferably.

That impulse is understandable; it’s behind some vendors’ efforts to create “do it once, remember it forever” options for saving and re-using favorite pages.

But too often, there’s another impulse on the heels of that one: I could care less about data mining, or defending myself in case of a chart audit, or making it easy to compare my “numbers” with my peers’. Less, in other words, about any concern but my own documenting speed and ease.

Newsflash: if you count yourself among this group, the days when speed and ease were your biggest worry are OVER.

There’s a reason for going along with clicks, and it’s spelled D-A-T-A. With it, you and your fellows can go toe-to-toe with The Wolf, The Iceman, Jim, and his successor, Slim.

Just Click and Save, boys. Just Click and Save.

Once again, I’m attending the annual NextGen EMR Users Group Meeting on all that’s new and shiny in the world of high-end, integrated electronic medical record and practice management systems.

New faces and new directions this year, of course. And a terrific keynote address by Pat Croce, former owner of the Philadelphia 76-ers.

But this year, the prize for the most awesome personage goes to Dr. Jan Lee — engaging, encouraging, and passionate about quality health care.

And her focus this year is on a revamped version of an older technology: report generation. And if there was ever a cornerstone of The Next Big Wave of electronic records, this is it.

Gold Mine

What the heck is report generating, and why should you care?

You may have heard of a related, sexier phrase: data mining. Simply put, it’s the ability to treat your EMR like the database that it is, and to ask it all sorts of questions that you could never logistically do with paper charts. Every major EMR vendor should have some version of this capacity.

Without it, good luck taking your patient care to the next level of quality. It’s really as simple as that.

What Kind Of Questions?

Here are some typical examples:

• How many patients do I have taking Lipitor?
• What are the phone #s, mailing addresses, and emails of all my patients taking Drug X, which was just recalled this morning?
• Who are my female patients over age 40 who haven’t had a mammogram and breast exam in the past year?
• What percentage of my diabetic patients have had an HbA1C in the past 3 months?

Once you “ask” your system these questions, it should take something like 5-10 minutes, tops, to get answers for all four of them.

Any one of those questions would have previously involved manually pouring over each and every paper chart in your chart stacks. Just visualizing the manpower needed to do so for all 4 questions, accurately, should make you want to curl up into a little mewling ball.

It’s not hyperbole to say that pre-EMR, asking these kinds of questions would have been impossible.

Who Should Care? EVERYONE!

The benefits of asking and answering questions like this apply to everyone: you, your patients, your insurers, and potentially the entire American health care system. I’m a big proponent of win-win-win scenarios, and this is definitely one of them.

YOU win, of course, because you can generate actionable information that could save your bacon, or bring home more of it.

• All those patients overdue for various health maintenance actions — a physical, a mammogram, a colonoscopy, an eye exam — can be found and listed, then reminded to “maintain” their health.
• If you keep track of when patients with problems have closure — coming back from a specialist, or getting specific lab tests — you can search for those patients who have failed to close the loops, and remind them to do so, and why it’s critical that they do.
• Negotiating with payers about your reimbursement rates? It’s a lot easier to argue (especially from an organizational standpoint) when you can prove your patients’ compliance with Pay For Performance guidelines exceed national or local standards — like how 97% of your diabetics are up to date on their HbA1C’s, 92% have LDL’s less than 100, and 100% of them have had a dilated retinopathy exam.

THE INSURERS win, because their patients are demonstrably getting quality care, which translates into fewer and shorter hospital stays, and less sick (i.e. costly to insure) people.

And of course, YOUR PATIENTS win, because the natural human tendency towards procrastination and self-delusion — letting things slide generally means letting medical problems ripen and spoil — is being countered by a passionless but tireless EMR, that focuses on the facts.

If you’re too cynical to believe in win-win-win scenarios, think of it this way: Is it in your patients’ best interests to have you remind them to take important action on their health?

There’s an awful lot going on these days.

Increasing awareness of the plight of American Medicine. Costs way up, access questionable, uninsured numbers growing. Primary care disappearing, and inverted in proportion to specialist:PCP ratios in other countries. The Graying of America. Talk about universal health care. Healthcare costs as being the #1 cause of personal bankruptcy in this country. Mid-level provider extenders.

Retail clinics.

Defensive medicine, and the over-utilization of expensive tests.

Just defining the scope of the problem is enough of a challenge, and lies outside the scope of this medical record blog.

But whenever I’ve read about strategies to fix the system, all of the serious ones involve EMR’s.

It Wasn’t Us, Honest

Although EMR’s have been guilty of many things in their short time on the planet, tanking the American healthcare system isn’t one of them. We were doing a fine job of opening the vents long before they came on the scene a decade ago (and even now, nearly 90% of physicians still don’t use them).

None of the issues at the beginning of this post have any kind of genesis with electronic medical records. And before you want to file EMR’s under “costs way up,” think about that $1500 MRI you ordered last week, or how a PCP after 40 minutes of coordinating care and counseling, earns 1/4th of what specialist can in 5 minutes.

A handful of those ka-chings, and you could pay for a high-end EMR for a year.

Think About Losing Weight

Consider it from another angle: What do you do when presented with a supposedly insurmountable problem?

If possible, you start by comparing it to something similar that you know how fix. The Weather may be way too complex — I only quote Chaos Theory, I don’t actually study it — but obesity is about right: it’s all around us, it’s a big problem, and very resistant to change.

And what’s the first thing you tell patients who want to lose weight? The thing that people who have successfully lost tons of weight – 80, 90, 100+ pounds tell you?

You’ve got to write everything down.

Put it down in black and white, all the stuff that pertains to your weight: nutrition, exercise, morning scale weight, etc. Count those calories. “I think I ate properly this week” is notoriously imprecise and generally wrong. What did the numbers actually show?

If you don’t measure it, you can’t correct it.

And there are an awful lot of administrators, public policy makers, and economists looking very closely at correcting the course of the USS Healthcare.

Lesson #1: At least for the clinical end of the stick, we aren’t going anywhere nationally, without EMR’s to record and measure what we’re actually doing, and to give us real data to work with.

Gathering said data with paper? With the expansion of the patient population? Then extracting, mining, and otherwise analyzing the info? Forget it.

But We’re Doctors, Not Statisticians Or Politicians!

Does the phrase “data mining” set your teeth on edge?

Or how about the thought of actually manipulating something with those numbers, like changing how you order certain meds, or whether someone needs to be called on the carpet because of a patient satisfaction survey? Don’t you just hate that?

It’s time to get over ourselves.

Our aversion to doing exactly that may well be a major factor in the ailing American healthcare system. An unexamined healthcare spending life may or may not be worth living, but we’re all sure paying for it. And it doesn’t need to be that way.

As medical providers, what our politics and numerical analyses often tell us, is that Doing What’s Best For The Patient is the overarching Rule Of Gold. Not realpolitik, and not zero sum game theory.

What works best in our daily slog through the mud, is what helps the patient get or stay healthier. This is less of a theory, than an observation — and if we disagree on this one, the whole rest of the argument falls to pieces.

Physicians who are policy makers and number crunchers may disagree on economic theory, but find it hard to argue this fundamental premise of medicine. When the numbers don’t add up at the end of the day, it’s sometimes the one thing that lets you sleep at night.

Lesson #2: There IS a lodestone, and that’s Taking Care Of Your Patients.

The problem, of course, is that it’s not always obvious what the best way is to do that. Especially across multiple practices, regions, disciplines, and regulatory bodies.

But That’s What Evidence Based Medicine Is For, Isn’t It?

Yes.

Forget about the legal hole you’d be in, if you did medical therapy instead of an angioplasty and your patient died — science itself, much less medical science, exists precisely because What Is Obvious Ain’t Necessarily So, and Common Sense Is Not So Common.

If a treatment works, it should hold up to scrutiny; if not, it’s time to revise our understanding of the problem, not cling to shadows. Evidence based medicine is the scientific method, writ large on the page of healthcare, and most of us understand the need for it.

So where does EMR come into this?

Evidence based medicine changes patient care patterns among clinicians, using analysis of hundreds or thousands of patient cases at a time.

But front line clinicians are only one part of the healthcare system. Just like documenting a patient care visit is only a small part of the benefit of an integrated EMR/EPM system, there are many, non-clinician aspects to the healthcare system that can be tweaked.

• What would you need to change not only patient care patterns, but also marketing patterns among medical groups?
• How would you analyze what went into setting the price point for a service, involving physicians, therapists, office and hospital stocking practices, and suppliers?
• How would you track waiting time trends, or the time needed to get a first appointment?
• How could you compare long term outcomes data for subsets of patients, not only weeks after a procedure, but months or years after?

How, in other words, would you track everything else in the healthcare system beside what the doctors do?

It all begins with an integrated EMR system.

If we can track it, we can kill and eat it.

But without the capability to analyze and optimize all aspects of the healthcare system, we’ll be forever stuck in our corners, trying to grab whatever fast moving targets flit by that day.

And the system’s problem isn’t a grab bag of small, quick, elusive targets. It’s a big, leggy Kraken that’s gotten used to waving its limbs around pretty much whatever way it wants to.

But then again, so are most medical practices, pre-integrated EMR’s (medical records, medication lists, chronic conditions, scheduling and appointment management, consultant coordination, follow-up tracking, etc). And though I defy any integrated EMR practice to precisely corral The Slimy Beast, taming it is, we’d all agree, both possible and pretty commonly doable.

But the first step is to track it. And for the magnitude of what we’re facing system-wide, nothing less than widely adopting EMR systems will do.

What would the perfect…or rather, a nicer EMR look like?

I take issue with that recent FPM opinion piece by Dr. Christine Sinsky, “e-Nirvana: Are We There, Yet?”

As an EMR consultant who works with both physicians and an MSO, I find it lopsided and unhelpful.

Yes, I’d like my EMR to be seamlessly integrated with my personal workflow, unobtrusive, and a snap to use. But as one of my junior high teachers used to say, Well, there are a lot of things I’d like in life. Simply “putting Google on the project,” as Dr. Sinsky suggested, might or might not take us closer to making the magical EMR a reality.

Google’s essentially unlimited financial and programming resources do tip the odds in favor of success. But so would putting the Almighty behind the project. And while I do pray daily, I believe there’s a certain due diligence in getting the apple down off the tree and into my mouth.

The plain fact is that for medical providers, stakes are high, time is short, and the amount of info to be juggled is frickin’ monumental.

We are in an EMR transitional period: relatively few doctors’ offices use one, yet there’s a clear federal as well as medical community mandate to get “EMR literacy” within the next several years. Not surprisingly, EMR’s are evolving, and are not as transparent, elegant, and powerful as they doubtless will be someday.

Google is, as a matter of fact, already on the case, and it will be interesting indeed to see what comes out of the Mountain View headquarters, with its essentially limitless financial and programming resources. All combined, the big EMR vendors can’t match the programmer and support staff numbers of Google.

But as much as I like the idea of having Google on the case — I gratefully use Google online apps — I’m not interested in faulting NextGen, AllScripts, or eClinicalWorks for not being the equivalent of The One True Google. From my “insider” perspective as a physician EMR user, who assists with EMR implementations, and works with programmers and support staff to customize a particular EMR, that’s a pointless comparison.

If I were an American pilot helping the Brits fly Spitfires in the Battle of Britain, I wouldn’t be criticizing Vickers-Armstrongs (the manufacturer of those fighter planes) for not being Lockheed Martin (the maker of the F-22 Raptor, the current supposedly best air superiority fighter in the world).

Plus, that Spitfire was one awfully sweet plane to fly, by all accounts…

What We Can Learn From Aviation

One of NextGen’s teaching mavens, Dr. Cephus Allin, used some aviation videos when discussing EMR’s, which is curiously apt. For better or worse, modern physicians — especially primary care physicians — are being put in the position of fighter pilots, although without any of the glory:

• They are THE “pointy tip of the spear,” usually the first point of contact for any and all medical issues, simple or nauseatingly catastrophic
• They have limited time frames to view, assess, and act on each patient encounter
• The amount of data they must process to do this well is enormous – past history, chronic conditions, meds, consultants’ notes, lab results, tests done and not done…
• They must routinely juggle other unexpected inputs during patient encounters, such as oh-by-the-ways as well as office matters outside the exam room

Thirty years ago, fighter pilot info overload was an area of intense study: there were too many dials, too many sensory inputs, and way too many ways to crash a jet that had long surpassed humans’ ability to control without computer assist. Heads Up Displays (HUD’s) were born, and dials and knobs were reduced from hundreds down to a dozen or so. And none of the critical data required taking your eyes off where they had to be.

It doesn’t take a rocket scientist — just an aeronautical engineer — to realize there will be some happier doctors out there once EMR interfaces become more streamlined.

If Only It Were That Simple

But any doctor who’s surveyed a bunch of EMR’s could have told you that. A doctor in the market for an EMR will light right up, if you can convince him your system is uncluttered, transparent to his workflow, and speeds his patient visits along with documentation shortcuts.

If you have to keep your eyes “on target,” where is the target? The patient in front of you, of course! Right?

Nope.

The person in front of the provider is more like altitude or airspeed information on a jet’s HUD: critical, absolutely, but — unfortunately — not the whole dogfight. Of course it’s important that you care for the patient, listen and empathize, and that your EMR doesn’t get in the way of that. But you’re not just trying to make them feel listened to, or leave happy.

You’re trying to make sure that they not only leave happy and healthy, but that they stay happy and healthy. Longitudinal goodness.

Now a lot of things can happen once a patient leaves the office, not the least of which is ignoring medical advice; it’s hard to make warranties that last beyond the front door. So maybe a better analogy is, you’re trying to guide your patients, to periodically nudge them back on course.

What’s outside of the cockpit for a PCP, then, is that snarling, furball-shaped, ever swirling target: the long term health of the patient with lots of attached variables, including compliance issues, who sees the doctor intermittently and not entirely predictably.

Ergo, how a patient looks, or what they may say during a visit, is only part of the picture.

Ergo, having an EMR that “stays out of your way” during a visit should only be a part of the search for a better EMR.

Quick and intuitive are great, I want those qualities in my EMR, too. But not at the expense of corralling the furball.

Why Google’s Win Isn’t A Sure Thing

I’m not interested in betting money against The Big G.

But there’s one thing that Google does not have an overabundance of, and that’s mucho man-hours of “flight test”: multiple iterations over thousands of medical provider and staff users using the product and giving corrective feedback.

The Cleveland Clinic announcement just came 2 months ago; most of the large EMR vendors have been refining and struggling in the crucible with patients, providers, and each other, for years

And as I’ve alluded to in this prior post, one of the biggest advantages to an EMR isn’t actually from the EMR — it’s from an integrated Practice Management and office workflow system. Doctors are understandably focused on documentation, but that’s only a fraction of what goes on in an office: appointments, billing and insurance confirmation, interoffice messaging, individual pharmacy and lab interfaces, and connections to referral specialists and hospitals. The greatest streamlining can actually occur in these so-called “other” areas, and all of them must be individually integrated practice by practice.

There’s no such thing as a standardized implementation; ten miles in any direction and the players change completely.

Google can teach us all a lot about cleanliness of interface and portability of data. And of course, a whole lot about searching for data in the middle of haystacks.

I’m just not sure how it’ll handle the part of an EMR system outside of the doctors’ hands. Managing millions of users’ accounts containing a handful of apps isn’t the same thing as managing thousands of medical practice accounts, each containing thousands or tens of thousands of databases (patient files). And at the end of the day, I personally haven’t found that it’s about a pretty interface, or finding my patient named John something who has a dog named Chip.

It’s really about helping the provider keep the patient on track. And there’s nothing like experience in defining what the track is, and individualized, local attention to set up specialized systems that’ll survive long enough to track that track over a patient’s lifetime.

And those are two things that Google doesn’t have in the EMR area. Not yet.