It’s been a while since my last rant about Electronic Health Records (EHRs), so let’s remedy that right now. EHRs in their current iteration are — how to put this delicately? — an unmitigated disaster. Nevertheless, much of the criticism of EHRs, including mine, has been in the destructive category. What about some constructive criticism? How could EHR software be made better?
I am not familiar with every EHR system out there. In fact my experience is pretty much limited to one system, which shall remain nameless, though I will give some clues as to which EHR I mean: its name contains four letters, two consonants and two vowels; the name has no pure rhyme in the English language, though it does have some near rhymes, such as the word septic; and the software is under the delusion that it is running in hyperspace, which may indicate that the programmers possess a sense of humor. There, I hope I have been obscure enough so I don’t get into trouble like I did before.
Current EHRs were developed before the mobile revolution, and it shows. Sure there are some mobile clients available, such as the puzzlingly Japanese named mobile app for the above-not-mentioned EHR system, but these mobile apps don’t match the functionality of the parent application, and, at least in my experience, have been virtually useless. It was possible though not practical to run the full EHR application in a virtual machine on a tablet. Being a Windows based program, it was necessary to have various awkward, non-intuitive gestures in order use it, for example, in order to right-click. This was not a natural interface for an Android or iOS tablet though possibly a Windows-based tablet, such as the Microsoft Surface, might work better. I don’t have experience with the Surface, so I just don’t know how much it would help.
Having your EHR running at full functionality on a mobile device is very important for a number a reasons. First, every doctor already has a mobile device of some sort. Second, the alternatives to mobile devices are immobile devices, i.e. desktops, which take up a lot of space, are expensive, are constantly breaking down, and are apt to have security issues, such as the doctor forgetting to log off, thus exposing sensitive patient information to the next person who sits down at the computer. Remarkably, the desktop route seems to be the norm for hospital EHRs, with doctors queued up during busy rounding times waiting to get on a computer. Third, doctors are inherently mobile. In the hospital they go from room to room when they round. It is much more efficient to carry one’s EHR with him or her and just go from room to room than it is to go to a room, return to the nurses station to type into a desktop computer, then go to the next room and repeat the process. Having a truly mobile EHR would avoid the constant trips to the nurses station. So why can’t an EHR fit into a mobile device?
One reason is that present EHRs try to be all things to everyone. They are not just for record retrieval and note taking. No, they contain everything and the kitchen sink. The same EHR used by the doctors is used by the admissions office to check in a patient. You may have no reason to enter anesthesia notes or insurance information but your EHR seems to want to do all that and more. Rather than breaking down EHR functions into different tools for different user roles, all functionality is combined together into one megalithic beast. Such a beast simply can’t fit into the mobile form factor. So we are left with the antiquated desktop computers, taking up precious space in the nurses stations, with quaint, 1990s style user interfaces that would rouse feelings of nostalgia if they weren’t so frustrating to use. And don’t get me started on the do-nothing “click-me” buttons that are required for “meaningful use.”
We used to have mobile record-keeping systems in medicine. They were called “charts.” Sure they were bulky and unwieldy, and often all the information that we wanted was not in them (most egregiously missing were X-rays). Nevertheless they were relatively portable, could be stacked on a mobile rack, and a doctor could go from patient room to room without having to return to the nurses station (other than to get a cup of coffee). Data input was via a pen, which is actually a very quick, if sometimes illegible, way to enter data. For all the deficiencies of such a primitive record keeping system, it was fast, productive, and allowed more face time with patients — qualities that current EHR systems don’t possess.
So, a well-designed EHR system — something that I don’t believe exists today — would take that old-fashioned model and make it work on a mobile device, such as a tablet. The doctor could go room to room, pull up the patient data, and then record, either by writing, dictating, or typing, a note. The key to making data input work on a tablet is brevity. Get rid of all the garbage that is automatically sucked into a progress note by today’s EHR systems: lab reports, X-ray reports, 12 point reviews of systems, accumulated cruft from old notes. If you look at the notes generated by these EHRs, the amount the doctor actually enters is typically very small. It is contained in the history section which often simply says something like this: “no change” and in the plan, which may be “s/p PTCA, discharge tomorrow.” All the other debris in the note is added merely to satisfy the coders and billing personnel, who will freak out if there the note isn’t long enough (low complexity of patient care, missing review of systems, etc.). They don’t really care if it is all just cut and pasted from the admission history and physical, as long as all the components are there for them to check off. As I have argued elsewhere, the close coupling of billing and documentation has to change in order to alleviate the current EHR disaster.
A useful EHR system is possible. For it to happen the current desktop-based model has to be thrown out. We need to start over and develop a truly mobile EHR. One suggestion: get the input of doctors when designing an EHR. Now there’s a novel idea!