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Saturday, October 22, 2011

The perfect electronic medical record

I have had a love hate relationship with our computerized medical record since we first started using it in 2007. Much like computers in all of American society, the idea that our computerized medical record is just a small facet of what we do, involved in the storage of information, is a gross simplification. In the US (also elsewhere, but I can't speak for Europe or Asia from much personal experience) the ubiquitous presence of computers has affected how we work, play, think, communicate. These interfaces with brains that we use so frequently have made us fatter, more connected to each others' thoughts, less connected to each others' bodies, has reduced our ability to use non-visual senses, has partially convinced us that 3 dimensions are optional, and I could go on for hours (at which time all hope of going out for a walk would be gone.) In my medical office, my near-umbilical connection to my laptop has touched all parts of what I do. The production of a document, which integrates information from as many sources as I am aware of that refer to my patient, is one of the most important goals of a visit. I also try to solve the patient's problem and answer their questions and listen to them, but I do it within the context of my computerized medical record. This sounds overstated, but in my particular case I think it is pretty accurate. So the fact that our particular software package sucks is profoundly irritating.

Now "sucks" is a pretty strong word, and I only use it because we just had an update which has been as infested with bugs as a cheap motel and I am frustrated. Oh so slow. I feel like some sort of a bivalve sea creature as I wait for the screen to allow me access to my patient's vital information. I feel trapped and claustrophobic as I attempt to stay within one layer of the record while needing simple information such as what happened last time or how old they are, that exists but is clicks away. The love part of "love hate" comes in when I see how many great features there are, including the ability to communicate to other doctors in my practice and support staff and pharmacies in a way that is accurate and nearly instant, and the fact that I can organize and transmit information that is coordinated and readable to the patient or to unconnected physicians in a printed format. That doesn't sound like much, though, in return for essentially marrying a computer.

I can, however, imagine a computerized medical record that I would really love, and have been doing that exercise for the last few days. I will now state what I want, and maybe at some time in the future, the universe will provide.

I would like my documentation system (EMR, for electronic medical record) to allow me to record information quickly and efficiently. I would like it to remind me to do things that I don't want to be thinking about while I am trying to concentrate on listening to my patient and formulating a reply or solution or whatever is called for. I want my EMR to keep me from doing obviously stupid things. I would also like it to tell me how late I am getting for my next patient. This is not much to ask, and I know computers can do this stuff. In fact, it may be that somebody's EMR somewhere in the world does do this.

When I first sit down with a patient, my nurse has been in the room, has gotten vital signs (blood pressure, weight, pulse, temperature) and, time allowing, has asked what issues the patient has and even typed them up in the medical record (yay Joy, you are an awesome nurse.) I would like my EMR to have already given my patient a chance to answer some of the more routine questions, such as "is this really your medication list?" and "in addition to your issues today, do you have any alarming symptoms such as passing blood or fainting or chest pain?" When I first looked at the screen it would show me a summary of the most recent medical visit and labs, so I would be reminded of salient information. I would then like to have a discussion with my patient about what they want help with and the stories, questions and answers surrounding that (the history of present illness.) I then want my computer to prompt me to ask questions about the corresponding systems. (Patient says "trouble swallowing", computer brings up review of nose throat and intestinal system "do you have post nasal drip, cough with eating, vomiting, heartburn or blood in the stool".) I then want it to remind me to review the background information: still in the same job? marriage? family history, clues to stress related issues? medical history? Then I will do my physical exam. I want it to highlight any abnormalities of the vital signs (sometimes I don't notice until later that the patient's blood pressure was elevated) and come up with a form to document my exam that is consistent with what I normally do. After I finish that, I would like it to highlight any area that the complaint suggests would need more careful examination. Then I want it to ask me what medical orders I wish to add and which medications I wish to prescribe or change. If I order a medication that interacts with another or that the patient is allergic to, I would like it to tell me (it does this now, but in such a ridiculously lame way that it is unusable). If I order a test or procedure that has been done or ordered in the last year, it should tell me that, too. Then I want it to suggest patient education handouts which I would press a button to print out. I would then tell the patient what I am thinking, ask if they had any other questions and the EMR would notify the nurse to come back in and it would lead her through a brief review of preventive medicine recommendations to tell the patient (due for a mammogram, stuff like that), but only once or twice yearly for any given patient. The nurse would also then make sure the patient had prescriptions and followup information which would already be clearly documented in the record. As far as reminding me how late I am, I would like there to be an appointment bar at the edge with present time and color coding and actual numbers to indicate how long my upcoming patients have been waiting.

Could I go through all of this in a 15 minute appointment? Depending on the complexity of the problem, most likely yes. Would the patient feel heard and supported? I think yes. I know for sure that if I spent less time in combat with stupid evil software  I would have more mind and heart to spend on being a human helping another human in need.

Computerized medical records are here to stay because their potential for improvement in communication is so awesome. The most important trick is for us to make them facilitate real care of patients rather than let them suck us into their information vortex only to have us lose sight of what we as caregivers are for.


Anonymous said...

Excellent vision about what you want. Might be irrelevant since you already have an EMR, but my company custom tailors our EMR to the exact specs of a doctors requirements. I'm talking from a code/programming level, not just configuring w/in an existing EMR which is what most EMR companies refer to as "customization". Some of what you want already exists w/in our system like "late reminders". Anyhow, thought you'd like to know that what you want is possible.

Brian Leekley said...

Consider asking a computer expert to do a system analysis of your computer and how it handles the software. Perhaps the slow response problem is solvable. Like, I bought a Flip camera and then couldn't watch the videos I filmed because my computer has less speed than required. I can only play a video at reasonable speed if I shut down all other programs, including virus checker and whatever. Maybe you need a more powerful computer, or need to be sure nothing else is running in the background, or need to change some settings, or something. An expert system analysis might figure out a way to improve the response.

Janice said...

Brian--unfortunately the "latency issue" (euphemism for having to wait just long enough to say 5 naughty words but not long enough for a meaningful meditation) (also known as being painfully slow) was network-wide, not specific to individual computers, and probably has to do with some part of the program that runs when it shouldn't. I am not at that job now, but I think the repairs are ongoing.