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Key features of a dream EMRs/EHRs

November 16, 2009

I’ve been in my residency program for almost 5 months now, and over that time, have had a chance to work with a few different Electronic Medical Records (EMRs) a.k.a. Electronic Health Records (EHRs).

There are two different beasts:  a hospital records system and a clinic records system.

I’ve also used a few in-office EMRs. One is a non-Physician IT Office (PITO)-approved one, and the other, one of the main PITO programs in use in my city called MedAccess. Each has its faults and strengths, but it comes down to two big things:

  1. if it crashes regularly or is boggy and slow, we will ALL hate it
  2. if it isn’t easy or intuitive to do basic tasks (like renew prescriptions or do billing), we won’t want to use it

Generally, I support the idea of a universal record, like a provincial medical record that would work both in-hospital and in clinic. The clinical version would have to be somewhat pared-down, and yet include extra features (like workers compensation documentation, well-baby records, and a different billing structure).

In hospital, things are generally more comprehensive than in clinic. Unfortunately, in all places I’ve worked, we are still dependent on a paper chart for progress notes and (often) for order recording. I have used hospital record systems in 3 other Health Authorities, and each was a different program with advantages and disadvantages.

I should probably also declare that my undergraduate courses were in Cognitive Systems, which has a lot to do with human-computer interfaces. As such, I come at this with a slightly deeper than average understanding of what computers CAN do and how they SHOULD work with humans. On the other hand, I’ve never personally (financially or emotionally) invested in an EMR, so I don’t really know what it’s like to be in EMR Purgatory.

If I had a dream Hospital Record System, it would have these features:

Accessing Data:

  • able to view all past progress notes/consultations with ease
  • display of inpatient and outpatient lab data
  • display of inpatient and outpatient/private service imaging reports, and the ability to view the original images by a click (i.e. link to PACS)
  • automatic inclusion of Pharmanet (prescription tracking system)

Entering Data:

  • able to type in or dictate progress notes directly into the system; inclusion of templates like the Admission History and SOAP note structure
  • some capacity to include a line-drawn image of the body (front/back), head (front/back), hand (front/back, L/R) in order to indicate injury or exanthem patterns
  • direct order entry with provisions for medical learners and verbal orders via nurses
  • a place for nurses to enter vital signs and have them graphically plotted

Connectivity:

  • linked to the patient’s family practice clinic record
  • consistent software or inter-connectivity throughout region/province/etc.
  • companion software for PDA/iPhone; i.e. doctors can view Rounds List (and basic patient data) on a mobile device and record ‘stumps’ for progress notes

Output:

  • capacity to print outpatient prescriptions and to formulate a discharge summary that automatically includes in hospital meds, lab results, etc.
  • ability to print out a summary for patients to keep in their own records

Technical:

  • remote access-capable
  • secure – login/password or access key/password
  • no allowance of user to lock computer (i.e. be-logged in or logged-off, not ‘reserve’ a terminal)
  • includes the use of terminals that can access stored data during maintenance down-times
  • doesn’t crash!

What am I missing?

One day, the computer will be a helpful tool rather than a barrier to interaction and productivity. We are getting close!

6 Comments leave one →
  1. November 19, 2009 8:18 pm

    I have often wondered about why hospitals aren’t more computer oriented- I figure them to be as, if not more, important than banks- and I can walk into a bank and they can tell me what my transactions were going back farther than I need to know (3.23 at the gas station years ago? not important)

    Yet when I go to the Doctor, he’s all, “Do you know if you’ve ever taken any antibiotics?”

    Who tells children, “You’re taking antibiotics. Remember this so in ten years you can tell your Doctor.”

    He seemed to not be very worried about me not knowing if I’d taken antibiotics or not, but … couldn’t that be important?

    Anyways, my point is that it would be much more reassuring to patients like myself who are a little anxious and don’t know much (changing, thanks to your blog), if there was a computer who remembered us wherever we went.

    Reassuring, until something like the Matrix happens…

    • November 20, 2009 3:30 pm

      we are getting close with the computers; we should learn more from the banking and aviation industries, but in healthcare, change is slow

      there are some facts that are VERY important for doctors to know, like which medications you are taking and if you have any allergies. there are certain conditions (diabetes, wolff-parkinson-white [a funny heart thing]), etc. that drastically change the way we manage your care, and would be good to know about BEFORE we start testing for everything. If a patient doesn’t know their medical history, they should carry a record with them, or at the least, have a family member with them who knows the details.

      A medical record accessible by all physicians treating the patient means we will not have to guess when you say “oh, they did a surgery for something in my tummy.” We always have clues – like the scars on your abdomen – but it there would be less room for error if we simply had it documented.

    • November 20, 2009 3:31 pm

      oh, PS, if you want a really good blog by a doctor that helps patients figure out how to interact with their doc, check out http://askanmd.blogspot.com/ Doctor D is awesome!

  2. Dave Walker permalink
    November 20, 2009 1:03 pm

    any thoughts about connectivity/interoperablilty to the patient’s personal health record (PHR)?

    • November 20, 2009 3:25 pm

      well we don’t have PHRs much in Canada, though I hear Telus will be offering Microsoft’s HealthVault at some point.

      It would be fantastic if the patient’s PHR were simply a reduced version of the EHR, i.e. the list of medications, medical conditions, allergies would all be documented there, but the details of each visit (like a SOAP note) would not. I’m all about empowering patients and simply being an “expert” resource to help enable them to achieve health, but I don’t think it’s necessary at all times to share all details of my expertise. A lot of medicine is in how you frame things. Whiplash recovery, for example, is highly dependent on patient factors and not correlated well with the degree of measurable injury.

      There would be problems with transparency at times. While I try to be honest and forthcoming with my patients all the time, sometimes I write things like “non-compliant with cardiac meds” or similar to communicate to myself (or any doc following up) that the reason the blood pressure is so high, or the CHF so poorly managed, is not for lack of prescriptions. There are other diagnoses too, like anxiety or psychosocial concerns that don’t always strike the right chord with patients, and sharing all details would be anti-therapeutic as it might diminish rapport. I’m not a paternalist in most scenarios, but there are sometimes where a patient is truly not competent in one sector of their health.

      We’d have to be careful about choosing which information to release on a regular basis, though of course, patients can apply to have their whole file as they can with paper charts.

  3. Courtney permalink
    February 1, 2011 12:53 pm

    I think we are honestly coming to the point in our society where it’s really crunch time. Providers realize that they can’t keep walking this line of paper vs electronic much longer. The move towards EMR is taking off at an increasing rate.

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