EMR Apps Taking Off, Starting with Refill Requests

About ten days ago, the new Technology Editor for Healthleaders magazine (Scott Mace) interviewed me about a range of healthcare information technology topics, and within a week he put out an article - these writers are getting quick!   He was especially intrigued about healthfinch, the company I helped co-found last year to build HIT tools which, "make life easier for physicians, and better for patients".  We talked a lot about our first product, RefillWizard, which is an "EMR Extender Tool" that uses the new concept of "team-based decision support" to help improve efficiency (by task-shifting work away from physicians and towards their team) AND quality (by increasing compliance with protocols).

I've talked about these ideas in previous posts (Rise of the EMR Extenders, Need for New Clinical Workflows and EMR Usability Update), and have hinted that I was working on putting these ideas into reality... I guess now the cat is out of the bag!   So if you have an EMR in place and want to implement tools which actually decrease the amount of work your physicians have to perform (while improving quality and documentation), then check out what we are doing!

Of note, Scott did a great job of explaining our philosophy and I liked how he stressed the importance of getting clinically active physicians more involved in these types of companies.  He even says at the end that if someone like DrLyle can do this - then anyone can!!!  That's OK - I know what he meant :)

Here is the article, with a few addendum from me in brackets:

EMR Apps Taking Off, Starting with Refill Requests

Scott Mace, for HealthLeaders Media , April 24, 2012

Lyle Berkowitz, MD, has graced the pages of HealthLeaders Media before, but with the new twist his story is taking, healthcare technology leaders everywhere should take notice.

Berkowitz was one of the HealthLeaders 20 in 2008—"20 people who make healthcare better."  [At that time], Berkowitz had recently founded the Szollosi Healthcare Innovation Program while continuing his primary care practice at Northwestern Memorial Physicians Group, the largest primary care group in the city of Chicago.

Now, in addition to these ongoing duties, add entrepreneur to his CV. In the process, he's using more technology to disrupt current healthcare best practices.

"I'd argue that primary care physicians should never have to be directly responsible for preventive care measures," Berkowitz says. "When I say that, people gasp. But when you look at the most efficient clinics and some of the highest-quality clinics, they actually have shifted a lot of that work to nurses who are very focused on that particular issue."

Back in 2010, Berkowitz was speaking on this very topic at the Mayo Clinic's invitation on how EMRs could make doctors' lives easier. In the audience were two young aspiring consultants who got so excited about a mock-up Berkowitz was showing, they proposed a new company to put actions behind Berkowitz's philosophy and inspiration. Thus was born Healthfinch. Berkowitz is chairman and chief medical officer and leaves the day-to-day operation to his partners.

Today, Healthfinch ties into most popular EMRs and runs prescription refill requests through a Web service, making it simple for physicians to delegate those refill requests to nurses and other medical office support staff.

At Elmhurst Clinic, based in nearby Elmhurst, Ill., one physician using the Healthfinch service is seeing real productivity gains. He sees less than half the refill request messages he used to see, according to Elmhurst Clinic CEO Donald Lurye, MD, MMM, CPE.  [To clarify, it was one physician interviewed, but their group actually has over 50 doctors using the system and they are each saving around 15-30 minutes a day!]

"The management of refills is a major activity, particularly in primary care where you're dealing with a lot of people with multiple chronic illnesses, that can have complicated prescription regimens and necessarily so," Lurye tells HealthLeaders Media.

"Dealing with refill requests sounds simple but it isn't. Many times, there's a need for a physician taking a look at a chart to decide whether a refill is appropriate. It can involve checking to see whether various types of follow-up have occurred, or whether certain lab tests have been done in a timely manner, that either just need to be done for monitoring or should be there to guide the therapy."

Healthfinch's rules-based engine, configurable by the Healthfinch staff in collaboration with customers such as Elmurst, automates the decision-making and offloads it from doctors.

When I first heard of this concept, I figured there might always be some super-cautious, belt-and-suspenders type physicians who would still insist on checking every detail.

"First of all, the protocols that Lyle presented to us initially were very conservative, and correctly so," Lurye says. "In fact, in his own personal use, he was still looking at every refill request. He just wanted to see, 'Okay, these are the things I think can be done automated. Now let's see if I actually agree with myself.' And we did the same thing here. And we've kept it fairly conservative. So that's one answer.

"And again, if we ever needed to they're fairly easy to adjust."

As for the rest of the care team, "it really makes them feel much more like participants," Lurye says. Refill requests can be "opportunities for patient education and encouraging people to come back in for necessary care."  [It turns out that the Nurses and staff like it more than we initially would have thought - they love being able to answer patients more quickly rather than playing EMR message-tag with their doctors.]

Deployed initially in primary care, the Healthfinch service will find its way into Elmhurst's specialty practices, Lurye says.

Healthfinch is extracting info from the NextGen EMR in use at Elmhurst. I was surprised that existing EMRs don't yet have the refill-request-delegation features built into them.

"The evolution of EMRs didn't really come from the clinical side so much," Lurye says. "The real return on investment on EMRs initially was that they helped to do charge capture better and meet coding criteria for various types of visits. They've become over time much, much more clinically oriented, and that's great."

Berkowitz sees EMRs as a platform on which a multitude of apps can be built, much as apps now get built on mobile platforms such as Apple's iOS or Google's Android.

"EMR vendors are pretty much focused on Meaningful Use right now," he says. "Nothing in Meaningful Use really says, 'Make a tool that makes the doctor more efficient.' Our tool doesn't help Meaningful Use. It simply helps the doctor be more efficient and provide higher-quality care."  [I love this line!]

EMR vendors are beginning to open up their platforms to allow third-party vendors to build these apps. "Allscripts and Greenway are leading the charge," Berkowitz says. Others will follow. For now, that means apps such as Healthfinch have to find more cumbersome ways to extract and use data.  [We have built our systems in a way which actually makes it now so hard to get the data we need from EMRs.]

But clearly this notion of EMR apps is going to be much, much bigger than just delegating refill requests. The healthcare ecosystem, ranging from payers to caregivers and encompassing financial analysts, quality mavens, and researchers, is starting to tap vast quantities of patient data that will accelerate the pace of innovation in healthcare technology by leaps and bounds.

To me it's very encouraging that there are physician-leaders such as Berkowitz who, while keeping their day jobs, have found ways in their spare time to advance this ball. The message is clear to healthcare technology vendors: If the Lyle Berkowitzes of the world can get this done, you should, too—and more.  [Well... I've been waiting long enough - glad my hat is in the ring now!]

View Online at: http://www.healthleadersmedia.com/print/TEC-279324/EMR-Apps-Taking-Off-Starting-with-Refill-Requests

And here was a summary from another HIT blogger who picked it up the next day: http://www.hospitalemrandehr.com/2012/04/27/will-next-generation-emrs-be-platform-stack-of-apps/

Clinical workflow that is just not sustainable

I am officially a huge fan of "futurist" Jeff Goldsmith (President of Health Futures). In my last post (I can't believe it was over a month ago), I quoted his thoughts about how "core measure mania" and the lack of innovation in HIT are resulting in a failure to address horrible EMR interfaces which make it harder for physicians to improve quality and efficiency.

In a recent interview in California Healthline, he elaborated further by explaining, "It isn't merely the tools that are the problem, but the fact that we have this micro accountability problem with the payment system and increasingly with the quality measurement process. We're absolutely inundating caregivers on the front lines with a level of detail that's required for them to document in their clinical workflow that is just not sustainable…. we're diverting a huge chunk of the clinical work force's available time to feeding the machine."

Bang - he nailed it right on the head.  Said another way, one of our fundamental problems is that we are using EMRs to force doctors to document for billing purposes - which takes a lot of time and energy.   And our EMR vendors keep giving us slightly refined versions of the same process, essentially saying "this upgrade will make it a little easier to do this really hard and unsatisfying task".   Instead, we need systems that focus on helping physicians (and other clinicians) actually take care of their patients, and make documentation the "byproduct" of that care.   I know, it sounds like common sense... but it just is not happening to any significant degree (don't worry - I, and hopefully others, are working on it).

Other great quotes from this interview:

I would have given meaningful users of clinical IT who actually followed the embedded care guidelines ... a malpractice shelter. That would have been the approach I would have taken is to carve out some kind of exception and reduce their malpractice expense.
Cool - I like this idea.  Instead of the government "piecemeal" giveaway of $40 billion dollars, why not use that force and energy to actually change the system... with the knowledge that short term incentives rarely provide long-term gains... it is much better to change the system at a large sense. 

I think at this point the meaningful changes are going to come from the margins not from the core vendors.
As with every industry with a lot of "big companies" who have trouble innovating due to their size, watch for the rise of smaller companies who will be creating products and services that will work both with and without the existing HIT infrastructure in place.  

Other interesting announcements of particular relevance:

* CMS launches their Innovation Center, with a goal to create better experiences of care and better health outcomes for all Americans and at lower costs through improvements.   It appears their method will be to "identify and test care models that provide beneficiaries with a seamless care experience, better health and lower costs” (per physician Richard Gilfillan, the acting director for the new center, in their news release).
* ONCHIT launches SMArt (Substitutable Medical Apps, reusable technologies) - an iPhone like platform which will allow developers to create apps using consistent standards.   And yes, this is VERY exciting stuff - something I've been talking and lecturing about for the past few years... can't wait to see how this unfolds!
* Video montage of HIT Usability Problems - from Canada's Healthcare Human Factors Group

The Real EMR Incentive: We want LONG-TERM EFFICIENCY, not short-term funding!!!

This is a mantra I have long been espousing, and it was nice to see a recent report from the CapSite research firm backing up this assertion.  More specifically, this study of more than 2000 medical groups across the US found that "the most important reason driving Ambulatory EHR purchases was the goal of physicians making their practice more efficient and not the ARRA / HITECH Act Stimulus funding".

Said another way, to get real adoption - we need to figure out how to promote USABILITY not just Certification.  And let's continue to move from the inefficient paper-based paradigm (EMR 1.0) to the much more appropriate web-based or iPhone paradigm (EMR 2.0).   My last post, which talked about "The Future of EMRs", provides more details on this idea.  And I am looking forward to learning more on this topic when I go to SanFran this week for the "Annual Meeting of the Human Factors and Ergonomics Society" - where I will be listening to the top experts across all fields, as well as speak on a panel of EMR aficionados discussing the importance of improving usability of these tools.

So what can we (especially the government) do if this concept is true (the key to adoption is Efficiency)?  Maybe we should reconsider how we spend the $30+ billion in HITECH funds?   Perhaps instead of giving "relatively" small grants to a lot of doctors, we use the money to help the whole industry create more Efficient and Usable products?   Myself, and others, have brought up this concept before (see "How should we use $36 billion to promote EMRs").   But it becomes more relevant when one of their own ask the question, which just happened:

As reported in this article, at a recent DC conference, former Secretary of the Treasury Paul O'Neill (who has authored academic papers on patient safety with current Medicare chief Dr. Donald Berwick and Lucian Leape) posed a technical question to keynote speaker Dr. David Blumenthal, the National Coordinator for Health Information Technology: "Why is it that we're reluctant to declare that we are going to design the best prototype that we can with an idea that we will have [iterative versions] as we learn more and we identify more needs?  Why is it that we can't call to question and get on with what's a clear and apparent need for a national standard that's a work in progress?  It's not that it has to be perfect from day one, but your office basically says, 'We're going to do this now?'," O'Neill said before a packed house of doctors and administrators of corporatized health systems. 

Dr. Blumenthal's answer did not clear things up as he talked about analogies to the interstate highway and the Internet - which actually seemed to hurt his own conclusion.  In other words, if you look at those government investments - you see that they created the infrastructure upon which others could build.  They did not involve the government giving money to end-users (e.g. local truckers) to buy and install concrete paths themselves, nor did the government give money to Internet end-users to buy and install web-servers themselves.  And yet, here we are - giving money to end-users (physicians) to buy and install a variety of proprietary systems that don't talk to one another without heavy lifting since each vendor creates their own versions of the concrete road - with proprietary data models and back-end functionality.

If the government believes in these past analogies - then they need to reconsider how they distribute their EMR monies...perhaps building a single standardized EMR platform (like they do with highways or Internet protocols) upon which the vendors can add their "value" and healthcare providers and patients can benefit from consistency and competition around the key issue at hand - Efficiency.

The Dark Side of EHRs

Sir Cyril Chantler noted, "medicine used to be simple, ineffective and relatively safe; now it is complex, effective and potentially dangerous." His quote was from a Lancet article in 1999 - much before EMRs were being used regularly. I wonder what he would say now!

I blogged back in February about the FDA's consideration of regulating EMRs... and a series of recent stories have come out reminding us of the unintended consequences of using information technology in healthcare… the truth being that problems occur due to a combination of issues, including;
• Implementation problems, such as forcing through awkward workflows.
• Technical problems, such as failed integration, slow speeds, system outages and true errors in the system design (e.g. 1 + 1 = 3).
• Usability problems, such as difficult to read screens, which can affect speed and judgment. Something I've been commenting on a lot in the past year, as in blogs of April, 2009 and August, 2009.

Here are two interesting stories from the Huffington Post Investigative Fund (a new nonpartisan nonprofit dedicated to in-depth reporting):
As Doctors Shift to Electronic Health Systems, Signs of Harm Emerge : A device that is central in the shift toward electronic medical records systems has been linked to instances of death or injury, according to an Investigative Fund review of Food and Drug Administration data.

Amid Digital Records Surge, a Lack of Policing by the FDA: As federal officials encourage the rapid expansion of electronic medical records to help doctors improve care and cut costs, they lack a reliable and systematic method for tracking the safety of these products, agency data and audits show.

Finally, my friend Dale Sanders, a well-known healthcare CIO, wrote an excellent blog bringing the personal touch and common sense thoughts to this topic of Patient Safety and EHRs.
I love this quote: Remember when safety belts in automobiles first became popular? They were simple lap belts, no shoulder strap. Did they aid passenger safety? Yes, in some ways… but they also introduced the danger of a whole new range of injuries, such as lumbar separation and paralysis, which hadn’t previously existed. It wasn’t until we added shoulder straps and the three point anchor to seat belts in cars that the evidence of benefit to passenger safety became clear and without question. We need pause now and add shoulder straps to EHRs.

If you are interested in searching the FDA's database for HIT problems, or submit one of your own, you can do so at MAUDE (Manufacturer and User Facility Device Experience)

With all that said, this should not stop the forward march of EMRs and HIT from helping us improve the quality and efficiency of healthcare... but it should certainly remind us that we are FAR from our ultimate destination and we all (vendors and users) have to figure out how to build, implement and use these systems better and better...

Other stories and articles
NY Times article (April, 2010) on how EMRs in the exam room can provide so much info that it pushes a doctor into “cognitive overload”

The Extent and Importance of Unintended Consequences Related to Computerized Provider Order Entry (JAMIA, 2007)

Overdependence on Technology: An Unintended Adverse Consequence of Computerized Provider Order Entry (AMIA Conference, 2007)

The unintended consequences of computerized provider order entry: Findings from a mixed methods exploration (Intl J of Med Informatics, 2009)

Rush to Electronic Health Records Could Increase Liability Risk
(Insurance Journal, June, 2010) which references this paper:
E-Health Hazards: Provider Liability and Electronic Health Record Systems

Nov, 2011: EHRevent.org has been created in collaboration with medical professional insurance carriers and adverse event reporting and government experts to improve EHR and patient safety and help to reduce professional liability. EHR event reports will be provided to participating EHR vendors and kept confidential by PDR Secure™.  Information from the PDR Secure PSO may be used by medical professional insurance carriers and the FDA to better understand EHR events and to develop education materials that will increase patient safety and benefit physicians and other clinicians in their use of EHR technology.

If HITECH Does Not Work, What are the Options to help with EMR Adoption?

The HITECH incentive plan (estimated at around $38 billon) was established to provide up to $44,000 to every outpatient physician who uses a "certified" EMR in a "meaningful" way (as well as $2-$3 million to each hospital). While its spirit has good intentions, I don't believe they will create a significant amount of new adoption in the outpatient arena because
- The amounts are too low (most systems cost much more to implement).
- There are severe shortages of qualified staff to help physicians convert from a paper to computerized system - a challenging task that includes IT knowledge, workflow redesign and general change management skills.
- The EMR systems are just not very good - both in form and function. See earlier blogs of mine about poor EMR Usability, from April and August, as well as a nice report by Dr. Peter Basch on the problems with current systems. Also check out a new podcast on EMR Usability in which I, and an IT Usability expert, discuss this topic in detail. Finally, here is the HIMSS WhitePaper on EMR Usability: http://www.himss.org/content/files/HIMSS_DefiningandTestingEMRUsability.pdf

So let's review two reasonable options - which are not mutually exclusive:

Change the Underlying Healthcare Reimbursement System
The government could forget the "on-time incentive" idea, and instead focus on long-term reimbursement changes that support quality and efficiency. As we know, our current reimbursement system mainly pays for the volume of "face-to-face visits". EMRs usually slow providers down, although can help them increase their coding levels for higher reimbursement. At best, it's a draw. What if the reimbursement system were instead based on quality (e.g. Pay for Performance) and efficiency (e.g. take care of patients, whether face to face, email or phone)? An EMR has much more potential to help here - by using decision support, establishing registries, and allowing for easy electronic communications. In other words, the government can just help set the reimbursement guidelines to focus on quality and efficiency, and then let the market work on optimizing care in line with that.

Create a Single Healthcare Data Platform
For a fraction of that same $39 billion dollars, the government could rather easily create a single data model and warehouse upon which all other applications can reside - thus solving standards and interoperability issues, increasing adoption, and creating a free market for the "best applications" out there. In fact, a conspiracy theorist might even suggest that the government assumes the current HITECH plan will fail...and thus they put a clause in the plan that says if there is not significant adoption by 2015 - the government can release some type of universal EMR...maybe the universal health database is what makes the most sense?

Several of us have been talking about this "iPhone" like platform in the past year, and here is a link to an interesting meeting that happened in May 2009, which resulted in the following: Ten Principles for Fostering Development of an “iPhone-like” Platform for Healthcare Information Technology
http://knol.google.com/k/kenneth-mandl/ten-principles-for-fostering/9x9jzgucudo6/2# .

And here are some videos from this meeting:
http://www.itdothealth.org/multimedia/2009-hit-platform/#videos

“Good software includes superb usability”

HISTalk just published a fantastic interview with Ross Koppel, PhD, a sociologist who has researched and published on the problems with HIT systems – focusing mostly on errors with CPOE, but can be easily applied to ambulatory EHRs as well.

At the beginning of the interview, he says something that needs to be better understood in the marketplace: “Vendors seek market penetration ASAP because user implementation costs prevent reconsideration of other options once a hospital or even medical practice is committed. But vendor product cycles do not allow the ongoing feedback and adjustments that allow rapid improvements. The vendors are eager to roll out new iterations while the industry structure does not encourage patient safety or the actual needs of hospitals and clinicians.” In other words - be careful with your first choice... it's a very long relationship and you better know what you are getting into!

He further elucidates that non-disclosure agreements (and/or other company policies) mean that when the vendors get feedback about problems, they are neither sharing them amongst all users nor are they prioritizing them based on true clinical needs. Specifically he says that “…the vendor picks and chooses on the basis of a market model and a marketing strategy, not on the basis of what is greatest for the greatest number of patients and clinicians. Now, if that were transparent and we could see that there are, of the 1,500 complaints, there have been 10,000 dealing with — those are categories of complaints — I don’t know, the impossibility of entering allergies, or when you enter an allergy, it wipes out the previous allergy. So if the first allergy was anaphylactic shock and the second was a mild rash to latex, anaphylaxis dies, disappears, and you get the mild rash to latex coming up.” In other words, do your best to make sure your vendor shares all the feedback they receive, and that the current customers have a strong say in prioritizing what gets fixed.

And I love this quote near the end: “Now, why do clinicians accept this? It’s because they didn’t go to law school. And by the way, I’m speaking very soon to a group of healthcare lawyers and the like. The CMIOs come to me and say, “Look at this, we bought this and now we can’t address this,” and the lawyers for the hospitals say, “Schmuck. People come to me with a $5,000 contract to make sure it’s passing muster. You signed a $100-million contract, and now you come to me now that you’re stuck”. Enough said.

And when asked what he would change, Dr. Koppel wishes there was simply better software to do what we all want, and intones the universal chant we are hearing more and more… “Good software includes superb usability”.

Bottom line, this interview should be required reading material for all CIOs and CMIOs working with any HIT vendors!

Also check out: The HIMSS WhitePaper on EMR Usability

Optimism, opportunity abound via cash for EHR fixes

The Modern Healthcare article I mentioned in a previous post quoted me as saying that for $36 billion of incentives, the government better make sure they are paying for improved quality and value, not simply for the use of present-day EMRs which do not automatically equate with clinical improvements. There were many letters to the editor about that article- most agreeing with this underlying premise.

Of course, there was one confused writer who actually said that EMRs must be fine since the vendors employ physicians... well, it is a nice thought, but basically that's the same as saying the banking industry must be fine since they employ MBAs - and we know that's not the case! The reality is that there are two flaws with this arrangement:

1. The physicians are not IT/Informatics savvy and/or the IT people are not clinical savvy. The problem is that the vision is wrong (eg "let's try and create an EMR that looks/acts like paper"), or the interpretation of the vision is wrong (we can't expect 20somthing year old IT programmers to understand how to model complex healthcare workflows without very deep guidance).

2. Even if you have a sophisticated informatics, future thinking Physician Executive who figures it all out - the marketing/sales team at the EMR vendor usually has a bigger say in development. Why? Because they are more concerned with selling to the "new customer" - and the "new customer" is usually naive about EMRs and thus they want a demo that looks/acts like the paper based system they currently use. It's definitely a catch-22...

So, here is the "reply" I sent in to clarify and expand on some of the things I said earlier:

Optimism, opportunity abound via cash for EHR fixes
In response to reader commentary on Joseph Conn’s “Rush for EHRs could ‘stick docs with bad systems’ ":

I am certainly pleased to see that this article has sparked so many great comments and responses. Of course, it is interesting to observe how different people have interpreted it through their own lenses, so I thought I would add a few more thoughts to the discussion.

First, I certainly think the American Recovery and Reinvestment Act of 2009 incentives for electronic health records are a good idea. I simply expressed my hope about how those monies would be distributed—specifically, that the government would define “meaningful use” based upon improvements in quality and efficiency (and not on just using a keyboard in an exam room). As it turns out, it appears that things are headed that way, and so I hope it continues in that direction.

Second, I’ll put on my primary-care physician hat and point out that while the incentives are a nice start, they are not enough. The government (and other payers) really need to change the whole healthcare reimbursement model to reward quality and value over quantity and volume. Once that occurs, we will see some true innovation in healthcare process and delivery that will certainly include robust adoption of EHR systems as an important tool to improve quality and value.

Third, I stand by my premise that current EHR systems need to do better with a lot of emphasis on improving their user interfaces, which need to be more intuitive and workflow-savvy. This problem with EHRs has been confirmed by recent studies showing both poor adoption rates as well as poor benefit realization in healthcare systems with mature EHR implementations. And while there are also some excellent implementations of EHRs throughout the nation, they usually require a huge amount of time, effort and money, factors we honestly can’t count on in the majority of locations.

Fourth, I am not saying to throw the baby out with the bathwater, but that baby has to start growing up. So how can EHRs improve? I think there are two critical components: incentives and usability. The more healthcare reimbursement incentives reflects the importance of features like quality reporting, registries, chronic disease management and virtual care, the more EHRs will move in that direction.

But that has to be paired with better usability that is very dependent on obtaining better physician input. While having physicians employed by vendors is a nice start, experience shows us that is certainly not enough. Rather, vendors need to start spending a lot more time with their actual users—physicians and other clinicians in the trenches. They should make their programmers go out and observe physicians using the systems they are creating, as well as use formal usability techniques to better understand how to improve their systems—the synergies and learning will be critical all the way around.

But be aware, if EHR vendors don’t start improving, and if there is not better adoption and better care, then the government may wind up using that money to instead create their own “iEHR” platform, which allows developers all over the world to create apps and widgets that meet every niche physicians’ need.

Finally, the title of the article was a warning, but one that can hopefully be averted—the overall message should be viewed as one of optimism and potential. At this moment of time, we have a very big opportunity, but with that comes a responsibility to make sure the physician’s voice is heard loud and clear as we move forward. Fortunately, we just have a very simple message: “Give us highly usable EHR systems paired with well-aligned reimbursement philosophies, and we will give you the best healthcare system ever.” - Lyle Berkowitz, M.D.

Improving EMRs: Usability, Usability, Usability

I've been working on physician adoption of EMRs my whole career, sticking to the mantra that "there are no benefits without use". And I've been fortunate in the past few months to be able to focus some extra time on this topic as part of a project on "The Future EMR" sponsored by the Szollosi Healthcare Innovation Program (http://www.theshiphome.org/).

I think this topic of Physician Adoption of EMRs is particularly relevent due to the recent Health Information Technology for Economic and Clinical Health Act (HITECH) bill for funding "meaningful use" of EMRs in an environment which has not yet seen much adoption, as evidenced by a Fall, 2008 NEJM article which found just 4% of US doctors using a "fully functional" EMR in the outpatient environment, and only 15% using a "basic one" (NEJM, July, 2008: Electronic Health Records in Ambulatory Care — A National Survey of Physicians).

So while adoption has many mothers, I'm going to suggest we are wise to focus on the "Three I's" to understand how to improve adoption:

(1) Interoperability: What a bugaboo. While many say that we don't have enough, I'd actually argue that we are so obsessed with this issue that we are losing the forest for the trees. In other words, let's get doctors using systems first, and worry about interoperability later. I realize that is a bit heretical, but the truth is that the majority of healthcare is local - and what we really care about is making sure that our EMR interfaces with our local PM system, lab, Xray facility, etc... rather than worrying about some regional or national sharing. The latter is still important, and there are always great anectdotes about having access to an ECG when on vacation, but let's start shifting some of the interoperability obsession to usability obsession (which I understand CCHIT is doing - and I approve!). Meanwhile - tell your patients (at least the sick ones) to keep a piece of paper in their wallet with: allergies, meds, problems, the names of their doctors and perhaps a copy of their ECG. I guarantee that one of the first thing paramedics do is go through someone's wallet or purse to look for this type of info.

(2) Incentives: No surprises here - we all know a system gets what it is designed to get, and right now, our healthcare system reimburses based on volume over value, and quantity over quality... and the former is pretty much what it gets. So clearly we need to create a reimbursement system that rewards physicians for value and quality... and if they achieve these things, they should get those rewards whether they use EMRs or not (but I suspect it will be easier to do this with EMRs than without). I think the HITECH bill is a positive step and truly a "stimulus", but we still need to figure out how to improve long term, day to day reimbursement to make sure doctors are rewarded for doing the right thing.

(3) Interface ("User interface" or "Usability"): This third point has always held great interest for me, since I have often had to use the systems I build. So I feel the pain when it takes 25 clicks to refill a med because EMR vendors still don't seem to understand that for me to refill a med, there is a ton of contextual data needed. For example, I need to know: what I was thinking at the last appointment (e.g. did I tell the patient to return in 3 months, and it has now been 5 months without a return), do they have an upcoming appointment, did the labs from the last visit alter my thinking on their follow-up, or has anything happened in the interval. In a typical EMR, I need to click all over the place to find this information - how come it can't just bring it all to me (answer- technically it is possible, but the EMR vendors just don't seem to get it).

This idea that the EMR needs to pull together and present "what we need to know and what we can do" is a recurring theme in my diatribe on Usability - the screen shots for specific workflows (e.g. med refill, lab review, phone message, office visit) should consolidate all the information I would likely need to review to complete that workflow (e.g. meds, labs, visit dates, notes) - ideally in a manner that is easy and quick to read: "Data visualization" may include graphics or other data manipulation (e.g. calculate the anion gap, or the Total/HDL values for me). Furthermore, the EMR should predict what I might want to do next and offer up those options to me (e.g. refill a med, order another potassium test, etc...). The result is LESS CLICKS - I don't need to go looking everywhere for data or orders- the EMR has brought them to me!!!

I talked in depth on this topic at the recent HIMSS conference and hired several graphic designers to actually build out some of these concepts as either screen shots or flash animation - these are by no means perfect, but they give some sense of interfaces that take advantage of how an EMR can make workflows easier. They will hopefully stimulate more thought and ideas in this area. The PPT below provides a summary of this talk (although I could not figure out how to upload the flash applications - so it will all be static screen shot here). I used SlideShare to upload the PPT and embed into Blogger:

Improving EMRs 2009

View more presentations from Lyle Berkowitz, md.

Post-Blog stories of interest
Wired magazine "re-imagines" lab reports: http://www.wired.com/magazine/2010/11/ff_bloodwork/all/1