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Eric Van De Graaff, M.D.

Last year I wrote a critique of the electronic medical record (EMR) my organization has adopted.  I came down pretty hard on its user unfriendliness and overall clunkiness, and expressed dissatisfaction with the office note that served as the final product.  In the ensuing months since I published my opinion I’ve come to be even more bothered by the weaknesses of not just our EMR, but the EMR landscape as a whole.

In doing a little psychoanalysis on myself I’ve come to the conclusion that my strong feelings about the shortcomings of EMR arise not from my disdain for the concept, but rather from my love of the idea of EMR and my disappointment that it can’t live up to its potential.  It’s like going out to a fancy restaurant where a great chef whips up a meal of the finest ingredients but which, in the end, tastes like cardboard.

But, as my grandmother always said, if you can’t say something good don’t say anything at all (of course nobody’s grandmother ever says such things, but the attribution makes the aphorism sound more folksy).  In reality, my grandmother was a little more to the point: “If you can’t write a blog on what the future of EMR needs to look like, then give up writing all together and get back to work.  And go fetch me some BenGay and prune juice while you’re at it.”

So, in honor of my prescient grandmother, here’s a letter I’ve written to all the EMR programmers, present and future:

Dear computer programmers and EMR developers:

Your product stinks.  The whole world of medical communication took a great big nosedive the moment you and your binary code inserted yourself into the business of medicine.  That doesn’t mean you can’t redeem yourself—you can.  Here’s how.

Rule No. 1: Remember why we keep medical records in the first place. Contrary to what you might think, the purpose of doctors’ notes is not primarily to enhance reimbursement or comply with government regulations; it’s to communicate.

Years ago doctors wrote notes to pass along information to their colleagues and to scientifically track the progress of their patients.  In the ensuing years we’ve lost the flavor of these original records—we no longer invest time and effort into describing our patients and their ailments with the literary élan of our predecessors (“This is a sad case of an engaging youngster, doomed to an existence as a chimney sweep and chronically disheveled but of cheerful countenance, who has developed a painless mass . . .”).  Doctors used the space in the record to chronicle their musings on the patient’s condition and to jot their analytical insight.

Medical records continue to serve this purpose, but only nominally, as outside forces have required the clinical chart to fill other roles.  We now have to add irrelevant information to satisfy billing requirements, document our discussions of risks to limit our malpractice liability, and insert scores of redundant data to assuage layers of government oversight.

So, despite the fact that your product has to address all these new demands, you still need to focus on creating a program that has communication as its primary function.  In other words, we don’t want any more notes that look like they were thrown together by a room full of monkeys on typewriters.  We want to go back to the coherent communication of the past.

Rule number two: keep it simple.  I have long maintained that computers have the ability to streamline the medical care environment and make all our lives better.  Right now, a clinic with an EMR in place runs slower and less efficiently than an office that sticks to the old, hand-written chart.  This doesn’t have to be the case.  Automation has enhanced productivity since the days of Eli Whitney and his cotton gin (whatever that is—some type of alcohol?) and there’s no good reason you can’t produce an EMR that actually makes me a more efficient doctor.

Rule No. 3: The product has to benefit patients. If our EMR doesn’t help us provide better care, then I suggest you quit the world of medicine and go back to programming video games and playing Dungeons and Dragons.  Take a hard look at the patient experience and figure out ways to make life better for them.  Focus on shorter waiting times, more comprehensive preventive therapies, and decreasing the risk of medical errors.

Here’s my list of what I’d like to see in an ideal EMR (Warning: the following discussion is mind-numbingly boring to anyone not in the medical field.  I strongly encourage you stop reading here and go back to watching cute cat videos on YouTube.):

  • Power up quickly.  Why does my EMR require several different log-ins and take minutes to load up, but my iPad applications can start up in nanoseconds.  There are probably a million reasons you’ll cite why this has to take so long, but with the current state of technology I don’t buy any of them.  Simplify the portal.
  • Go truly paperless.  My experience is that the more “paperless” we go, the more paper we end up using.  Figure out what gets printed and find a way to incorporate that into the program.  Trees are in rare supply but there seems to be no global shortage of electrons.  You never see stacks of paper or shred boxes on the sick bay of the USS Enterprise, do you?
  • Store data on the cloud.  I want access on my computer, iPad, smart phone, and even my toaster (once I get one of those fancy internet toasters).  Give us biometric access so that we don’t need a gauntlet of logon IDs and passwords.
  • Give patients access to their own records.  Each of our customers should have immediate and unrestricted connectivity to their data.  The moment I finish an office note it should appear in some database that patients can easily review.
  • Fix the voice recognition software.  I know the technology is out there.  Find some way to allow us doctors to mumble our way through a note and have it correctly translated into complete sentences, commas and all.  For years little old ladies have sat in darkened cubicles correctly transcribing doctor dictations with only rare errors—can’t you write computer code that rises to that level?
  • Start using artificial intelligence (AI).  If I can have a discussion about philosophy with woman name Siri on my iPhone, why can’t my EMR be smarter than it is?  I want a system that automatically schedules a follow-up appointment when I say “I’ll see the patient back in a month” and will send prescriptions to the pharmacy when I dictate “let’s start atenolol 50mg daily.”  I shouldn’t have to expend a single additional calorie re-entering commands into a system that can’t think on its own.
  • Provide feedback.  As it stands, my EMR does nothing to help me improve the care I provide patients.  I want a system that screens all my patients and flags those whose care has deficiencies.  Figure out whose blood pressure has been inadequately treated, who needs an updated blood test, which patients should be screened for peripheral vascular disease, and so on.  Medical science has produced reams of algorithms that allow us to provide better preventive care—they’re just never incorporated into our computerized system.  I want to know that my EMR is helping me provide the best care possible.

Someday there will be a Steve Jobs of the EMR world who will come along and produce a system that listens in on my office visit with the patient, uses voice recognition and AI to produce an extremely accurate summary of the discussion, and schedules all necessary tests and medications based on what I explain to the patient—all without me having to even interact with a computer keyboard.  The note will be instantly dispersed to the patient and all other caregivers.  The program will suggest any useful therapies that I may have missed and provide educational resources to the patient based on the subjects discussed.  And, of course, it’ll hit all the high points needed by the coders and Medicare overlords.

When this happens it’ll put every other EMR out of business; because, finally, we’ll have a system that actually helps us rather than hampers us.  If you can do this, dear programmers, then I promise I’ll write a three-page blog praising your name and extolling all your zeros and ones.  And, most of all, I swear to never again joke about Dungeons and Dragons.

Sincerely, and with hopeful optimism,

Dr. Van De Graaff



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8 Responses to An Open Letter About Electronic Medical Records

  1. Tara says:

    Excellent! I have hopeful optimism that the EMR world can be like this someday too!

  2. Loan Eby says:

    Dr. Van De Graaff:
    Why doesn’t the medical industry learn something from the travel industry? Here is the elevator pitch from the SABRE website: Sabre Travel Network provides technology to the travel industry. It operates the world’s largest travel marketplace, connecting travel buyers and sellers through the Sabre global distribution system (GDS). Its innovative technology connects 350,000 travel agents to more than 400 airlines, 100,000 hotels, 25 car rental brands, 50 rail providers, 13 cruise lines and other global travel suppliers. More than $100 billion of travel is purchased through this channel annually.” http://www.sabretravelnetwork.com/home/

    I know, adapting an oligopoly structure for EMR would put thousands IT companies out of business and computer programmers out of work. But then again, there would be an increase of antitrust cases to keep the attorneys busy. Which in turn would increase stress levels, which would bring more patients to your door, which would increase your patient case load, which would increase your need for an efficient EMR :0)

  3. Excellent observations.

    My multi-part series on the “mission hostile user experience” presented by today’s commercial health IT, with screen examples from actual systems (redrawn and edited to prevent IP issues) is here: http://www.tinyurl.com/hostileuserexper

    A site that addresses these issues in more depth that I use in my Informatics teaching is “Contemporary Issues in Medical Informatics: Common Examples of Healthcare Information Technology Difficulties” at http://www.ischool.drexel.edu/faculty/ssilverstein/cases/

    Finally, I am concerned some of the suggested technical solutions may require significant advances in ‘cybermetics’ (e.g., computer and information science) that are simply not practical at this point in time, and will not come from the health IT industry which is being stunningly enriched with its current products., while protected from adverse outcomes by hold harmless and gag clauses (see Koppel and Kreda’s JAMA article “Health Care Information Technology Vendors’ “Hold Harmless” Clause Implications for Patients and Clinicians” at http://jama.ama-assn.org/content/301/12/1276.extract ).

    Adverse outcomes do happen, by the way; a relative of mine was seriously injured and died as a result of EHR’s toxic effects on care, and other physicians I know pull their hair our over “close calls” from the effects of defects such as in FDA’s MAUDE database documented here: http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html

    S. Silverstein, MD
    Drexel University
    Philadelphia

  4. E. M. R. DeSigner (maiden name: DeVenter) says:

    • Power up quickly. Why does my EMR require several different log-ins and take minutes to load up, but my iPad applications can start up in nanoseconds. There are probably a million reasons you’ll cite why this has to take so long, but with the current state of technology I don’t buy any of them. Simplify the portal.
    Agreed, and this will improve over time. You’ve downloaded some 99-cent apps that fire up in nanoseconds. Here’s some tradeoffs which would help us speed up the process for you:
    • We can skip the step of polling for your patients’ most recent lab results and charted observations by the rest of your care team, and bring you back instantly to the items you documented about the patient yourself.
    • We’ll skip the steps where we’re seeing how long it’s been since you or someone else opened this patient record to highlight what’s new for you. And we’ll skip the step to see what time and date it is, to see what else you might be forgetting to do in your care plan for the patient.

    • Go truly paperless. My experience is that the more “paperless” we go, the more paper we end up using. Figure out what gets printed and find a way to incorporate that into the program. Trees are in rare supply but there seems to be no global shortage of electrons. You never see stacks of paper or shred boxes on the sick bay of the USS Enterprise, do you?

    Agreed, and this will improve over time. Hopefully your EMR (and the whole field in general) has never said “This is exactly how we envisioned this workflow…we’re done”. No, rather it was a means to make the transition off of your first few pieces of paper into the lesspaper realm. Also, let us know when all your patients can afford, have purchased, and know how to use their computer to bring this in, so we can stop enabling you to print off materials for them.

    • Store data on the cloud. I want access on my computer, iPad, smart phone, and even my toaster (once I get one of those fancy internet toasters). Give us biometric access so that we don’t need a gauntlet of logon IDs and passwords.

    To the extent which you could describe to me what “the cloud” is, your data is practically there. We can get to your data from just about everywhere. Let us know when each and every device has harmonized its operating system, security, supported development languages and connectivity approaches. We’ll support that framework pretty quickly. Also, let us know when your hospital or government or you all individually purchase that same device set so we know we’ve provided a solution for all of our interested users. Awesome.

    • Give patients access to their own records. Each of our customers should have immediate and unrestricted connectivity to their data. The moment I finish an office note it should appear in some database that patients can easily review.
    Your patients have access to their own records. Your patients have access to their own records—one each from any and every discrete system they visit. Ask your patients what they really want—that’s what we’re working on as an industry—a single record with all their patient health information, whether it’s from their visits with you or from the retail on-site lab storefront that offers the simple lipid panel at a fraction of the cost of what your employer is bilking them for. I could list some initiatives and acronyms but don’t want to scare you with non-medical jargon that would cloud your caregiving prowess and/or sound too much like we’re all socialists hard at work to get you to all march in lockstep.
    • Fix the voice recognition software. I know the technology is out there. Find some way to allow us doctors to mumble our way through a note and have it correctly translated into complete sentences, commas and all. For years little old ladies have sat in darkened cubicles correctly transcribing doctor dictations with only rare errors—can’t you write computer code that rises to that level?
    • Start using artificial intelligence (AI). If I can have a discussion about philosophy with woman name Siri on my iPhone, why can’t my EMR be smarter than it is? I want a system that automatically schedules a follow-up appointment when I say “I’ll see the patient back in a month” and will send prescriptions to the pharmacy when I dictate “let’s start atenolol 50mg daily.” I shouldn’t have to expend a single additional calorie re-entering commands into a system that can’t think on its own.
    Spot on. So we’ll get started on that. “New prescription for Mr. Kova…levAlbuterol 50mg three times a day before breakfast” We’ll e-deliver the request for Mr. Kova’s prescription for Levalbuterol as you requested (or wait, was that Mr Kovalev who’s supposed to get Albuterol?), and we’ll tell them to take it three times just before their first meal. Oh, and I won’t bug you by asking if I captured what you asked correctly—that would be annoying so I’ll just get that sent to the local drug store that I predict the patient goes to so they can get it filled and printed instructions based on what you said. Or that blood pressure reading you just spoke to the little microphone neatly hidden in your labcoat while texting back your golf buddies—was that standing? Sitting? Intravascular? Should I bother you to clarify or just log it ambiguously as best as I can? Yep, just as easy as asking Siri what the weather is.

    In agile development we utilize what’s called a backlog. So each little item we want to offer is incrementally worked on and shipped. Fill our backlog with each little bifurcation point occurring deep in your brain as you state your directives and we’ll build the algorithms to parse each sentence you may or may not form, bit by bit.
    • Provide feedback. As it stands, my EMR does nothing to help me improve the care I provide patients. I want a system that screens all my patients and flags those whose care has deficiencies. Figure out whose blood pressure has been inadequately treated, who needs an updated blood test, which patients should be screened for peripheral vascular disease, and so on. Medical science has produced reams of algorithms that allow us to provide better preventive care—they’re just never incorporated into our computerized system. I want to know that my EMR is helping me provide the best care possible.

    Wait—I’m confused. My boss here at the development shop just assigned me to eliminate my system’s popups warning about those critical lab values and absence of immunization and allergy data and those contraindicated drugs you just prescribed through your nurse. Are you using an EMR or perhaps Salesforce to do your physician documentation at your facility?

  5. J. Alberto says:

    Dr. Van De Graaff,
    Last year at HIMSS Interoperability Kiosk ONC sponsored a prototype (below link) that did exactly what you have outlined as requirements for the optimal EHR. Perhaps you can see the enclosed HIMSS 11 video and educate yourself on a very promising solution to the problem you highlighted.
    J. Alberto

    http://www.roverink.com/

  6. Eric Van De Graaff, M.D. says:

    Dear Mr. E. M. R. DeSigner,

    Thank you for taking the time to write your lengthy response to my recent blog post. I appreciate the input of an expert on the other end of this dilemma and your demonstration of the appropriate use of sarcasm in crafting your rebuttal. I take no offense at the tone of your comments, especially in light of the fact that I set the stage by taking pot shots at your profession (I am obviously not one who should be casting stones–I nearly failed a Fortran class in college).

    While I can appreciate your arguments about how simplistic my “wish list” must sound, I would like to share one observation. Years ago, when my best friend and I were in high school, tooling around in his 1969 Camaro, we used to crank the tunes of the day with the windows down in an attempt to lure all the hottest foxes in the school. For our playlist we’d take our collection of LPs and dub them to a mix-tape with supplemental songs recorded off the radio (we were too cheap to actually purchase all the music we listened to). That way we could cruise to the sounds of 38 Special, Bob Segar, Aldo Nova, and Foreigner, all loaded onto a small collection of cassettes.

    These days I often reminisce on my experience as i spin through my iPod’s massive playlist. The device connects wirelessly to my car’s stereo system so that I have the entire 70s and 80s at my fingertips as I cruise down the road with my foxy wife. If there is a song I don’t have it only takes a moment to take my eyes off the road, download the tune, get it started, and panic as I swerve to miss a gaggle of orphans in a crosswalk before I can continue on, enjoying the choruses of “You’re As Cold As Ice.”

    If I were to go back in time to 1982 and tell a room of computer programs about a “wish list” I have for car audio (“instant access to any song on the planet”) I would be laughed out of the room and face a barrage of pocket protectors hurled in my direction. Their excuses might just even sound like the criticisms you offer in your rebuttal. The fact remains, however, that, 30 years later, we now have the technology to do something no computer programmer in 1982 thought possible.

    If you’ve read Steve Job’s biography you’ll note that his career consisted of programmers telling him that what he envisioned wasn’t possible. He simply disagreed and pressed on with his “pie-in-the-sky” ideas, then he and his experts made the impossible come to fruition.

    Mr. DeSigner, I’m not asking for you to create my dream EMR today. I just want to remind you that we need to keep the big picture in mind as we move forward with our technology. We can’t let today’s technological limitations steer the course in this journey. We need to keep our ideals front and center as you and your colleagues assemble the ones and zeros.

    Thanks again reading my blog and sharing your comments.

    Dr. Van De Graaff

  7. John Willoz says:

    Dr. V –
    I am retired technology guy that tried to create systems for folks and I am also a volunter at Midlands and a Medicare aged geezer. Your points are all very valid. I will share a couple of thoughts from a designers view just for giggles.

    As I went through the design process of several large scale systems, one of the most difficult parts of the process was getting accurate, consistent, de-conflicted input from the users on what the system had to do. And additionally, since these systems were in the educational records, payroll and accounting areas we had to be aware of the myriad federal regs that govern so much of this. I cannot imagine the vast list of government based requirements that medical software must meet. Glad I am not in that arena. I offer this simply as another view. Your requirements are all valid and I would think that a reasonable developer would love to have someone like you as the “inputter” of requirements for system design. And since commercial systems many times are aimed at such a wide variety users they try to make everyone happy with one system and that can result in suboptimal systems for all users.

    I love your blog and I love your comments. I just hope your desires can be met in a reasonable period of time because I see great value in EMR systems. The last time I visited my cardilologist he asked if I knew when my last blood work had been done. I wasn’t sure of that date but knew my internist, also in the Alegent system, had done tests recently. Dr R was able to quickly access that data, see the results and save the time and cost of more blood work. I know that is a very puny example but to me that was very helpful as well as my internist being able to see all of Dr R’s results from my exam. Hang in there and keep pushing the system to be the way you want. But also be patient with us geeks. We want to help I promise.

  8. E. M. R. DeSigner says:

    Thanks for the response, Doc! Yep, sarcasm in good fun (and much of yours bounced right off from me–I get chastised here in the IT shop b/c I don’t get any of the Star Trek or Hitchhiker’s Guide to the Galaxy References people drop).

    And I understand the vision and the value in never losing sight of what’s *really* the goal in all of this as a solution. It remains a “be patient” chore in the meantime, while us behemoth vendors continue to scramble to keep our existing customers less angry & more certified, and to keep our prospective customers knocking at the door.

    If it makes you feel better, I, too, look at a pinnacle in design (and the metaphor meets with your aspirations for voice recognition…I just have my holy grail in typed form). On your google calendar….the quick add….you just type in whatever to represent an event (details in any order), and it gets it right…..puts it on your calendar, you’re done. The same logic will be what’s behind your future-state voice-driven system. Healthcare delivery has more moving parts than a calendar appointment at least one hundred-fold, but we’ll get there.

    ….I thought I recognized that guy headbanging to “Blinded by the Light” in rush hour the other day……

    Cheers
    -designer

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