Under a physicians’ microscope; medical and technology mash-ups

There is no question that EMR's are tools in the healthcare system, and not the brains behind treatment, decisions, or the delivery of care. EMR's are at the center of healthcare delivery as a documentation, order placement, order retrieval tool, alerts, and the repository for patient data and more. However, hospitals are still being held back with the same old issues of lack of EMR interoperability, leaving doctors to continue going on a scavenger hunt for often timely patient data.

While a pillar of patient care, hospital CIOs, CFOs and CEOs are also requiring EMR's to provide a better ROI than simple patient record keeping. C-suite executives must look beyond the actual cost paid to an EHR vendor as the only cost. They must look into the total cost, including providers in time to learn a new system, the migration and loss of patient data that has been collected in the current systems, the capital expense of system software, the hardware, trainers, IT personnel, etc. something that is currently being looked at as a necessary expense.

EMR antidotes
Meanwhile, medical pros are increasingly looking for EMR antidotes and wanting solutions that can operate more like technology mash-ups than simple record repositories, yet hospitals are slow to make changes. The Healthcare Information and Management Systems Society (HIMSS) notes that approximately $2.05 trillion is spent on EMR systems yearly. However, a study of 1,000 physicians by the MPI Group found that nearly 70% of physicians say the current electronic health record (EHR) systems have not been worth it.

One respondent noted that his office "used to see 32 patients a day with one tech, and now we struggle to see 24 patients a day with four techs. And we provide worse care". Another noted that "the failure of health information technology to quickly deliver on its promise is not caused by its lack of potential, but rather because of the shortcomings in the design of the IT systems that are currently in place".

"Poor EHR usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information between EHR products, and degradation of clinical documentation were prominent sources of professional dissatisfaction," the report found.
Physicians, nurses, clinicians and others are impacted by the design of EMR's in many ways. Most patient data is viewed as nested lists of documents or as tabular data displays. They are many pages deep and require scrolling in multiple directions to view. Physicians have to search for and hold various pieces of data in their mind or develop work arounds like taking paper notes as part of the decision making process.

Finding information in different EMR's is even more challenging as there is no uniform way of accessing the data. Different EMR's store information using different taxonomies, requiring medical pros to learn various programs to access the same information, or constant switching between different applications to obtain a complete picture of a patient's condition. A perfect example is an outpatient clinic where care was initiated and documentation placed in an ambulatory EMR. The patient was then admitted to a hospital where a different EMR exists for the continued management of care.

Mash-ups versus match-ups
However, this type of inflexible and difficult EMR data match up scenario is becoming less attractive and more outmoded as new EMR 2.0 solutions are being developed to eliminate these difficulties. There are tools that can access EMR data in a specific format that mashes-up the data with "smart" analysis, creating an actionable, information based diagnoses, enabling urgent yet accurate care decisions to be made. If you add the ability for medical professionals to interact with information in a standard way, and empower patients to share in their care, hospitals can provide a great solution to all parties involved while benefiting from economies of scale.

While a nurses' paper chart never saved a patient life, it offered a narrative of a physician's diagnoses and remedy. The paper chart communicated complex, evolving patient issues coupled with solutions in a standardized and accessible way. The information contained in those narratives was often difficult to read and not tracked in computers. However, any number of health care providers could create patient data from the various providers' perspectives.

Patient information should be contained within the EMR, but without the numerous barriers. The tabular display of data requires providers looking for patterns to reconstruct the trends in their mind as they transition between numerous dizzying EMR layouts. EMR design does not present the information in a convenient visual display to allow for accurate and timely decisions to be made.

Obtaining the view of a paper-based ICU flow sheet in EMR's today requires multiple mouse clicks and navigation to uncover vital signs, infusion titrations, ventilatory settings and changes from the prior day, fluid input and output, laboratory results, and significant nursing or consultant interactions with the patient.

A digital Florence nightingale

What is needed to streamline the entire EMR process is an electronic nurse's sheet that can address information the way medical professionals are used to. The tried and true methods that enabled care givers to build a continuum of care based on connected information and presented like the nurse's sheet notes. The note itself should be replaced by a single mobile platform where data can be accessed universally and not locked away in disparate EMR silos.

Not only is the view of data difficult to work with in EMR's, but navigation is also cumbersome. Patient information can be entered into various areas within the EMR, depending on where the provider chooses. A single blood glucose value can be entered in at least four different areas of the EMR, creating the chance of them being missed by another provider not expecting to find the information there.

EMR order entry information is another potential for patient error resulting from its difficulty to track. In a prior study by Bates, et al, hospital residents required an additional 44 minutes per day to enter patient orders. The added time and complexity of placing orders can cause providers to forget to enter something or a nurse missing to remove something already ordered.

Another issue with order entry is in the overall patient management. Within EMR's there is often a decoupling of order entry and clinical documentation. In the pre-EMR workflow, physicians document issues in the narrative progress note and comment on dealing with abnormal issues along with their decisions and treatment plan.

With EMRs, values are entered into the system they are captured from connected patient monitors or laboratory devices. When abnormal values log into the EMR, there is an inability to follow who is aware of these issues, and if they have been addressed. Although there is the ability to communicate this information to all providers, they are not yet part of the EMR system.

Can't All of Our Data Just Get Along?
The expensive implementation of complex EMRs has taken place supported by the HITECH act, replacement is not the answer. Instead, develop tools that interact with the data contained in these systems. There are already EMR 2.0 entry and communication tools that directly interact with this information while maintaining the original benefits of EMR's. Technologies such as middleware allow easy data access and avoid the unnecessary data duplication of HIEs. The use of open APIs for easy development of medical record application development. These solutions are available today and can help bring an end to the 1,000 daily medical error deaths and the trillion a year spent on the consequences.


Dr. Donald Voltz, MD, Aultman Hospital, Department of Anesthesiology, Medical Director of the Main Operating Room, Assistant Professor of Anesthesiology, Case Western Reserve University and Northeast Ohio Medical University.A board-certified anesthesiologist, researcher, medical educator, and entrepreneur. With more than 15 years of experience in healthcare, Dr. Voltz has been involved with many facets of medicine. He has performed basic science and clinical research and has experience in the translation of ideas into viable medical systems and devices.




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