[The following clinician guest post is by Dr. Shane O’Hanlon, and is the first international contribution to GeriTech. (I’ll let you guess where this geriatrician is from.) Thanks Shane!]
Unlike most physicians I don’t yet have the
luxury of an electronic health record. I still live in a paper world, where I
frequently need to chase down echo reports, lab results and duplicate charts.
Perhaps that’s why I have a pretty clear vision of what I want in an EHR. Every
day I can see how my workload could be improved, how I could literally cut
hours off my work-time by having better systems to manage the information that
I sift through. At the bedside the lack of availability of results is
frustrating but this is the least of my worries. Since I work in geriatric
medicine, almost all my patients have reams of notes, hidden in bulky charts.
There is no doubt that a problem-based approach is the best way to manage people
who have multiple medical issues but a new list is started with each admission
as the notes are never accessible.
luxury of an electronic health record. I still live in a paper world, where I
frequently need to chase down echo reports, lab results and duplicate charts.
Perhaps that’s why I have a pretty clear vision of what I want in an EHR. Every
day I can see how my workload could be improved, how I could literally cut
hours off my work-time by having better systems to manage the information that
I sift through. At the bedside the lack of availability of results is
frustrating but this is the least of my worries. Since I work in geriatric
medicine, almost all my patients have reams of notes, hidden in bulky charts.
There is no doubt that a problem-based approach is the best way to manage people
who have multiple medical issues but a new list is started with each admission
as the notes are never accessible.
So for those of you who routinely use EHRs,
I wonder if they are blinding you from seeing how they really should function?Have
we all succumbed to group think and accepted the way most EHRs currently need to
be dragged along with us as we work? Let’s start back from square one here. The
following five rules are my take on how you can make me an EHR that really
works.
I wonder if they are blinding you from seeing how they really should function?Have
we all succumbed to group think and accepted the way most EHRs currently need to
be dragged along with us as we work? Let’s start back from square one here. The
following five rules are my take on how you can make me an EHR that really
works.
Rule one : An EHR should follow the
consultation
consultation
–
Telling the computer what
happened during a consultation is a waste of time. I need my EHR to track the
interaction and make notes as it happens. Yes, this means natural language
processing. There is clear evidence that computers alter the doctor-patient
interaction and the triadic relationship that results has no place in medicine.
Why do we let computers have such a central role? Patients don’t want it and it
distracts us. Computers should help, not hinder our interaction.
Telling the computer what
happened during a consultation is a waste of time. I need my EHR to track the
interaction and make notes as it happens. Yes, this means natural language
processing. There is clear evidence that computers alter the doctor-patient
interaction and the triadic relationship that results has no place in medicine.
Why do we let computers have such a central role? Patients don’t want it and it
distracts us. Computers should help, not hinder our interaction.
–
As I take a patient history, I
want my EHR to grab soundbites – not even every single detail – and allow me to
confirm the individual details at the end. But I am never going to write out
the history word by word. I want the relevant points of the patient history to appear
onscreen in real-time so that I can pursue diagnostic algorithms and make a
focused problem list. For example when taking a chest pain history it should
guide me through the common cardiac questions but make sure I also ask about
relevant gastrointestinal or respiratory symptoms. Similarly as I examine I
should be able to dictate my findings directly to the record. And it should
prompt me if I skip something relevant.
As I take a patient history, I
want my EHR to grab soundbites – not even every single detail – and allow me to
confirm the individual details at the end. But I am never going to write out
the history word by word. I want the relevant points of the patient history to appear
onscreen in real-time so that I can pursue diagnostic algorithms and make a
focused problem list. For example when taking a chest pain history it should
guide me through the common cardiac questions but make sure I also ask about
relevant gastrointestinal or respiratory symptoms. Similarly as I examine I
should be able to dictate my findings directly to the record. And it should
prompt me if I skip something relevant.
Rule two: An EHR
should educate me
should educate me
–
When I see a patient I will often
think of something I need to look up or revise. I need my EHR to log this
learning objective and help me immediately find the information I need to fill
the gap, or remind me later. It should track my learning so that I can see the
improvements in my knowledge, and provide the opportunity for me to test myself
on it regularly. The core curriculum for my specialty should be integrated, so
that I never go too long without being reminded of the knowledge I need to
retain. And as things change I need to be alerted – up to date, curated medical
information from the literature should be streamed to me as it appears.
When I see a patient I will often
think of something I need to look up or revise. I need my EHR to log this
learning objective and help me immediately find the information I need to fill
the gap, or remind me later. It should track my learning so that I can see the
improvements in my knowledge, and provide the opportunity for me to test myself
on it regularly. The core curriculum for my specialty should be integrated, so
that I never go too long without being reminded of the knowledge I need to
retain. And as things change I need to be alerted – up to date, curated medical
information from the literature should be streamed to me as it appears.
Rule three: An
EHR should inform patients
EHR should inform patients
–
Similarly, at every
consultation there is something I teach a patient. As recollection of the
detail can be hazy later, I need the option of printing or emailing
high-quality patient information, written at an appropriate level. This should
happen automatically without my prompting. My management plan should be also
available to patients immediately after the consultation and in an accessible
format. For those who need more in-depth information, further resources should
be available. This should all be available in the patient portal that
integrates with the record. In my experience, most patients don’t want access
to their record itself, but they do want access to a summarised version that
contains the key points, written in an easily-understood manner. Both should be
available. And an open record will encourage me to keep my notes to the highest
standard.
Similarly, at every
consultation there is something I teach a patient. As recollection of the
detail can be hazy later, I need the option of printing or emailing
high-quality patient information, written at an appropriate level. This should
happen automatically without my prompting. My management plan should be also
available to patients immediately after the consultation and in an accessible
format. For those who need more in-depth information, further resources should
be available. This should all be available in the patient portal that
integrates with the record. In my experience, most patients don’t want access
to their record itself, but they do want access to a summarised version that
contains the key points, written in an easily-understood manner. Both should be
available. And an open record will encourage me to keep my notes to the highest
standard.
Rule four: An EHR
should audit me
should audit me
–
Just as it’s important to learn
from your interactions, it’s also an absolute necessity to be able to identify
areas of self-performance that can be improved. My EHR should do this by
itself, without my say-so. It should provide feedback and if necessary report
me to the authorities if I am clearly doing the wrong thing on a regular basis.
Linked to aggregated data, I should be able to compare my performance with my
peers and see where I am on a graph. My patient outcomes should contribute
anonymously to this database that would be used for audit. Audit leads to rule
five:
Just as it’s important to learn
from your interactions, it’s also an absolute necessity to be able to identify
areas of self-performance that can be improved. My EHR should do this by
itself, without my say-so. It should provide feedback and if necessary report
me to the authorities if I am clearly doing the wrong thing on a regular basis.
Linked to aggregated data, I should be able to compare my performance with my
peers and see where I am on a graph. My patient outcomes should contribute
anonymously to this database that would be used for audit. Audit leads to rule
five:
Rule five: An EHR
should improve patient safety
should improve patient safety
–
Audit will eventually make my
care better, but I also need the EHR to guide me to make the safest decisions.
It should question my plans if necessary and provide up-to-date information
where it is relevant to my management strategies. Why would we do any of this
if it just made our lives easier? The goal each day in healthcare has to be,
how can I improve the safety of what I do? How can I reduce adverse incident
rates? How can I improve the patient experience and achieve better outcomes? If
EHRs don’t do this, then they are not worth a penny.
Audit will eventually make my
care better, but I also need the EHR to guide me to make the safest decisions.
It should question my plans if necessary and provide up-to-date information
where it is relevant to my management strategies. Why would we do any of this
if it just made our lives easier? The goal each day in healthcare has to be,
how can I improve the safety of what I do? How can I reduce adverse incident
rates? How can I improve the patient experience and achieve better outcomes? If
EHRs don’t do this, then they are not worth a penny.
As you can see, I want my EHR to facilitate
my interactions. It should improve my communication with patients, it should
help me access information for work and for continuing professional
development. It could also use social media to help me network and compare
notes with colleagues, even seek second opinions. It should help me compare my standards
to other doctors. And it should watch me and intervene immediately if my
performance drops below standard. It should involve patients in their care, and
help them to engage better with their providers. The patient portal is a whole
other world where preventive medicine can be used to make an investment in
their future health. That is for another post!
my interactions. It should improve my communication with patients, it should
help me access information for work and for continuing professional
development. It could also use social media to help me network and compare
notes with colleagues, even seek second opinions. It should help me compare my standards
to other doctors. And it should watch me and intervene immediately if my
performance drops below standard. It should involve patients in their care, and
help them to engage better with their providers. The patient portal is a whole
other world where preventive medicine can be used to make an investment in
their future health. That is for another post!
In the meantime I welcome comments – how
close are we to realising my expectations?
close are we to realising my expectations?
Shane O’Hanlon teaches Health Informatics
at the University of Limerick, Ireland. He works as a hospital clinician in
geriatric medicine. Twitter: @drohanlon
at the University of Limerick, Ireland. He works as a hospital clinician in
geriatric medicine. Twitter: @drohanlon
hi Shane,
I'm especially intrigued by your first rule. Are you thinking of an EHR that actually listens to you speaking to the patient, and processes in real time? I wonder if anyone is working on such an EHR; haven't come across this idea very often.
Or how are you envisioning that your EHR would track the interaction?
thanks again for this terrific post! leslie
Here are my comments to your rules
rule one – Natural Language Processing applications already exist, and some EHRs already interface to these. Also, one can make notes on paper and dictate later, or record the conversation during. Many transcription services are more than happy to interface the dictation back into the medical record.
EHRs can help with decision support, but as you are well aware medicine is highly complicated so a full decision support system an EHR will most likely never be. And would you want it to be, really? I would think that some form of human decision is necessary…
Rule two – You can certainly make notes in EHRs that you can reference later. But it sounds like you also want it to be a medical education system here. While I think it would be a nicety, this is carrying the EHR away from its intended purpose. As for interacting with other physicians in a "social network" type scheme, some EHRs are already introducing this functionality into their systems.
Rule three – Many EHRs certainly do have nice information for patient education, based on diagnosis, meds lists and orders, procedure, etc that are easily added to and printed out on the after visit summary. And if set up to do so, will have all of this information, and more, on the patient portal.
Rule four – Several EHRs do have physician dashboards that can compare your performance to other doctors. And the EHR can HELP with an audit using certain tools, but because of the complexity of the profession and system a human should really be relied upon to actually perform the audit. Humans are fallible, and the systems created by humans can also retain that trait!
Rule five – BPAs, Best Practice Alerts, are available in many EHRs and have been for quite some time. The downside of items like these are physician "alert fatigue", a very real problem in the industry.
I certainly hope this information helps!