Yet Another Diatribe on EMR; This Time With Actual Suggestions

You might think that developing a system for EMR would be fairly
straightforward.  After all, some of the things that computers
really good for, are the storing, retrieval, and display of
information.  But somehow, developing a system that actually
works AND
is easy to use in a hospital environment, has proven to be rather

Reading a post on the blog, href="">Information
is Free (so help yourself.) I was reminded of a few thoughts
I've been meaning to disseminate.  This is on the topic of
electronic medical records (EMR).  It is not intended to be a
comprehensive analysis of the topic; rather, it is a loose collection
of observations and thoughts on the subject, plus some suggestions that
I think are worthwhile.

The first I heard about EMR was in the mid-1980's, at a lecture I
attended while in residency.  After the lecture, I asked the
guy (I think he was from Penn, but I am not sure) why he thought it was
taking so long to get EMR established.  He said that one
reason is that with EMR, there is absolute accountability.
 You can see quickly who is doing their job, and keeping up,
and who is not.  He thought that fear of accountability was a
big factor.  He did not think that it was resistance to
learning new technology.  

However, I have personally known retiring physicians who've commented,
that they are glad they are getting out of medicine now, so they don't
have to learn all that computer stuff.  So I think there was a
time when there was such resistance, at least among the older MDs.
 And it is the more senior ones who make all the decisions.
 Now that you have MDs who grew up with computers moving into
positions of authority, that should change.

As for the accountability thing, well, get used to it.  You
shouldn't be in health care if you don't want to be accountable.

But there is another factor, that has to do with the differences
between generations.  This one is not on the medical side, but
the information technology (IT) side.  The more senior IT
folks tend to think of databases and spreadsheets and word processing
as the main productivity applications for office work.  That
is how they are going to approach every problem.  They look
down their noses at things like Blogger, or or
as amateurish, not worthy of consideration as serious tools.

Yet, look at what the creative class is doing with computers: it's all
online, and it is all about generating, finding, sorting, and
displaying information to make it more useful.  It's a huge,
ongoing, collaborative, and vibrant laboratory for simultaneous
development and application of the principles of knowledge management.
 It's foolish to ignore it.  

For example, just think about the ScienceBlogs site.  It would
make sense for each department in a hospital to have something similar,
so each physician would have his/her own home page, with a list of
links (blogroll) to things like Medscape, e-Medicine, the Merck
Manuals, favorite CME sites, whatever; plus links to local copies of
especially-pertinent articles.  For example, I have a folder
at work with articles on Serotonin Syndrome, NMS, and the like: things
that come up from time to time, have to be managed correctly and
quickly, but which I do not see often enough to necessarily remember
how to manage.

In a hospital setting, each MD would be able to view the pages of other
MDs, to see what they are doing, and to adopt whatever looks useful to
them, etc.  The blog portion could be used to post general
notifications about planned vacations, etc.  With appropriate
tags, and clever RSS feeds, a secretary could then get notification of
each MDs planned vacations, to make sure there is coverage.
 Things like that.  There could be an RSS feed so
each MD could call attention to recent articles, for example.
 So if a neurologist saw something she/he
thought that all neurosurgeons should read, it
could be tagged as such and fed to all the neurosurgeons.
 That would enhance cross-disciplinary communication,
something that is sorely needed at the present time.

Each MDs home page could be easily updated with links to the records of
her/his current patients, although that part would be firewalled,
password-protected, and encrypted; but it could be accessed at home via
VPN, with appropriate security certificates.  

I'd love to be able to get up in the morning, make some coffee, log in,
and see if any new patients were admitted overnight, how they are
doing, whether anyone has wonky lab results, or was seen in
cross-coverage overnight.  By the time I got to the hospital,
I would already have an idea of how to go about my day, what my
priorities are, etc.  The nurses would have posted anything
that deserved priority attention.  The pharmacy would have
posted notices about potential drug interactions they picked up, or
orders that needed to be clarified.  The list of possibilities
is lengthy, and everyone could pitch in with new ideas.

And of course, in order to be most useful, the entire thing would have
to be free/open-source software (FOSS), or have a nominal licensing
fee.  It would most useful if widely shared.  It
would be most likely to be able to incorporate the latest
ideas/innovations if nothing is patented.  

Say, for instance, that each hospital paid $50 a month to subscribe.
 That is so low that everyone would gladly pay it.
 But it would add up to a substantial amount.
 Hospitals in developing nations would get to join for free,
and would get to see what is happening, and how things are being done,
at the best hospitals in the world.  Guess what?
 That would really help everyone on planet

If health care in Thailand is improved, it makes us safer in the USA.
 Think about that, all of you in the href="">Dept. of Homeland

Who would do the development?  Some MDs would help.
 But there probably are enough people in the FOSS community
who have had bad experiences in hospitals, that they would pitch in and
help, adding their own ideas to improve the system.  ( href=""
rel="tag">Pat Volkerding comes to mind.)
 A funded foundation, like href="">Wikimedia,,
could take the lead.  

What about security?  Some people think that having
proprietary solutions is the best way to ensure security.
 That's baloney.  Our experience with electronic
voting disproves that notion with a couple of exclamation points.
 There are plenty of people in the FOSS community who are
concerned about privacy, including the privacy of their own
medical records, that there would be plenty of expert watchdogs.

I'm sure there is a strong temptation for people to try to develop such
things and make them proprietary, but I would strongly
caution against that
.  It would be way
too stifling.  Health care is too important to be shackled
like that.  The absolute last thing we need is a proprietary
system, where the only innovations are done by people miles away from
the actual users, and where each innovation is a trade secret.
 That kind of thing will only get in the way, and could
actually lead to bad patient care.  

Suppose somewhere a nurses' aide comes up with a great idea to improve
sanitation, or whatever.  How is that information going to get
spread?  Right now, there is no way to do it.  But
having something like Digg, or Newsvine, could really help.
 It could save lives, literally.  The best ideas
would float to the top, and anyone who cared would see it.

All these ideas are already out there.  It just takes openness
and willingness to make it work.

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If you need the help of a librarian for this let me know.

By Christopher Gwyn (not verified) on 08 Jan 2007 #permalink

There already is a huge codebase for EMR systems. The entire VAs system (which has been using EMR's for years) has been released as a FOIA request, and is in the public domain.

One problem is that it is antiquated and difficult to work with.

Another librarian chimes in (I'm a retired medical librarian.) with a few thoughts.

It often helps to have someone (such as a medical librarian) to serve as a "translator" between the medical professionals and the IT people -- someone who understands how the software works but also knows the kinds of questions doctors ask and how they want to see the results of a query. For example, my experience shows that doctors often ask "associative" questions -- "I've diagnosed this patient with abc disease, but she also has xyz condition. Is there any info on how the usual drugs work in this combined situation?"

When it comes to individual patient records, the first page that pops up should have any and all info that is critical or important to any caregiver working with that patient: all current diagnoses (chronic conditions should have a "since" date), any unexplained symptomatology, known allergies, adverse reactions to drugs, failure to respond to drugs, unusual lab results, and all currently ordered medications.

Ideally, there should also be a page where all of a patient's future scheduled appointments for all services (with physicians, for lab work, for rehab or physical therapy, etc.) are listed. This can help you and/or your receptionist avoid scheduling conflicts, and may also help to decide when to see a patient (Ah! She has a neurology consult on the 5th; I'll wait to see her until after that, and I'll ask the neurologist to send me his findings.)

BTW, have you done a post on Serotonin Syndrome? If not, I'd be interested to see one.

A lot of these kinds of suggestions are like getting all concerned about whether or not the radio of a car receives satellite stations or not, when the problem is the car is too difficult to operate.

The very basic current problem I see is that the medical record is being destroyed. On a practical level it is unusable. And I'm speaking as someone with a lot of experience with computers, with a lot of tolerance of various GUIs and other ways of interacting with them.

What I mainly would like to see for starters is something like this: I walk on to the nurses station and insert a Flash memory stick into one of the computers. It immediately logs me on with a set of my preferences and all the programs running when I just pulled it out of the last computer I put it in. If I call up a patient's name, it automatically retrieves important current information and shows me some clickable links for anything from the past that is in accessible storage somewhere, maybe even links me to the EMR in our office. I get the info I need, and go see the patient, pulling out my memory stick, at which time it logs me off. After seeing the patient, I go back to a computer (same or different one, it doesn't matter) and I log right back to where I was.

These are capabilities of computers now, not sometime in the future.

I think that there are two views points to be considered when strongly advocating the use of EMR in practices. For a Doctor it needs to easy to use and save time so that more time can be spend on the patient. Currently we have many vendors with different types of EMR that are so hard to use that it simply puts them off. I think healthcare technology companies need to develop product after regular interaction with doctors to ensure that they provide just what is required. At binaryspectrum we have developed our healthcare solutions after spending countless number of hours with doctors to ensure that its work flow is kept simple and intuitive. This is then followed up with a period of Beta testing in real time environment before it is offered as a product in the market.