Is Google The Answer To EMR?

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.