Monday, April 26, 2010

EMR Complications

Pauline Chen wrote a piece in the NY Times on April 22, 2010 titled: An Unforeseen Complication of Electronic Medical Records which in many respects is an understatement. There are many untended consequences big and small and while the appreciation of the benefits:
  • fewer missing charts
  • streamlined information and
  • efficient work-flow patterns
It was with a smile I read the first specific problem identified at the outset
I realized I had no idea where to sit
With technology overtaking the office space and the design failing to take account of technology that was unimagined when the facility was originally on a drawing board it is not that surprising. The smile gave way to an element of sadness as I realized this was a problem I had faced when we built an innovative facility in Glasgow Scotland in 1993/4 that included a paperless medical record. We built mock up rooms, full size with all the components necessary for care to model the work flow, space an interaction. Including any PC was a challenge and the speed of change was best captured in the computer room. In the short 2 years it took to go from drawing board to build out the space allocated was halved as the technology got smaller, faster and cheaper and it was cheaper to cut the room in half rather than cooling the larger space.

Most doctors agree that the value of an EMR out weighs the costs (financial and personal) of implementing this disruptive technology;
Few, if any, of those interviewed would choose to revert to a paper-based records system. But all the physicians expressed concerns that EMR had less than salutary effects on the patient-doctor relationship, including difficulties replicating the narrative aspect of a patient’s illness and the constant interruptions from alerts and instant messaging
This remains one of the most persistent challenges and was true back in 1993/4 when we were implementing our paperless medical record. Doctors and patients are tuned into the same channel we all are WIIFM (what's in it for me) and to date the focus for most of these systems has been billing
most systems have been designed not with clinical needs in mind but to meet the demands of the fee-for-service payment system
In this rush to digitize the beleaguered clinicians has been forgotten and the rich characteristics of narrative than contains the fine nuanced detail necessary for rapid and complete transmission of information between clinical team participants is lost in digitizing and codification. As Dr Lin is quoted as saying:
How can you possibly point and click your way through a patient’s 10-year history
You can't and that's why the capture of the narrative and in particular facilitating that process without the requirement to, as Pauline Chen puts it:
spinning and wheeling back and forth between patient and computer than I did sitting still and listening
is an imperative in successfully rolling out EMR technology. Center to that is voice and facilitating the capture of this narrative without additional time burdens. To date Speech Recognition remains the only technology that has emerged to capture the narrative without burdening the physician. Historically the medical transcriptionist converted this audio into a structured, grammatically correct nicely formatted document. But today increasing volume of audio is processed using speech recognition technology that provides automation, efficiency and now in the clinical setting immediate conversion of this audio into digitized clinical content that is EMR ready.

Pauline is right clinicians need training to cope with this technology but I would suggest the less training that is required the better the adoption will be - just look at the iPhone, iTouch and most recently iPad. Apple took out complexity and created a device that an untrained 2 1/2 year old could pick it up and start using:


I'm not suggesting that clinicians cannot learn - but I do believe that design simplicity is lacking in clinical system and adding an intuitive and simple interface is essential. Part of that includes voice and intuitive voice control as can be seen here at the CES demo by Kristen Wylie



as well as voice capture as can be seen here in an interview of Dr David Stein here.

The status today - this technology is able to answer some of these challenges. Clinicians will be using EMR technologies in increasing numbers and Speech Recognition provides a bridge to the digital chasm between their need for patient interaction and the necessity to capture clinical data in EMR ready form.

Where are you in your implementation and what is helping and what is not. How does your doctor interact with you and what technology does he use?