Have you seen the award-winning Intel ad that walks you through the advances in technology as seen through the eyes of two thrilled geeks? In the 1980s, they are amazed by an Atari gaming system. In the 1990s, they are enthralled with email. And in the 2000s, they are awed by a wireless laptop. The ad plays on the mind-boggling leaps that computing technology has made in the last 30 years. Indeed, it has been an amazing journey. But it is a journey that until recently had left medical record keeping behind.
Where We Have Been
In 1985, the Journal of the American Medical Association published the article, “A computerized Summary Medical Record System can provide more information than the standard medical record.”1 The article concluded, “This improved flow of information could improve the clinical decision process.” More than 10 years later, researchers at Kaiser Permenente published a study on the effects of an electronic medical record (EMR) on patient care, noting that “clinicians perceive an improvement in patient care as a result of using an out-patient EMR system.”2 And yet, in 2008, authors writing in The New England Journal of Medicine were left wondering why only 13 percent of outpatient medical practices are using electronic medical record-keeping technology.3
Perhaps the answer is that while computer hardware has advanced exponentially in the past three decades, a lot of medical software has not. Physicians are often meant to hunt and peck on a keyboard or point and click on endless drop-down menus to generate a note, prescription, and bill. Doctors and patients complain that the computer erects a barrier between them.
While almost every industry has advanced information technology by forcing the computer industry to adapt to them, doctors have been asked to adapt their practice to out-dated technology. As the prospect of being penalized by CMS for not having an EMR looms ever larger, medical societies have provided their members with such—often impractical and time-consuming— advice as, “learn to type” and “separate…data entry…from your patient encounters.”4
Almost 30 years after EMR technology started becoming available, doctors have no use for an Atari gaming system in a Wii world.
Where We Are Going
While many physicians' offices do not have computerized order entry, your local quick-service restaurant does. In any McDonalds the person behind the register will quickly touch a screen that generates an order to the food preparers in the back and a bill for you, all in a matter of seconds. Restaurants have changed to these machines, as the technology has proven faster, more accurate, and therefore cheaper in the long-run.
According to the NEJM article, 66 percent of physicians cited capital costs as the reason for not adopting an electronic medical record.3 But McDonalds and many other industries have learned that capital outlays are well-spent if they save time. With the advent of tablet computers, it is now finally feasible to bring the same quick-touch technology into the exam room.
Forget everything you think you know about EMRs and picture a physician walking into an exam room with an iPad in his or her hand. Instead of endless drop-down menus and typing, picture an outline of a male or female on the iPad screen. All the physician has to do is touch the figure where he or she sees a lesion and then touch the correct diagnosis on an adjacent list. With a few more taps, a “smart” plan, note, prescription, and bill are generated. The patient and the doctor are barely aware that an electronic device is in the room, and the doctor's busy work is done.
This is not new technology. It is a demonstration of form following function. The iPad (and other tablet computers) now make it possible to bring quick touch technology into the exam room.
Touch screen technology is both user- friendly and quick, but it is not the only advance physicians have been waiting for. In order to finally have EMRs save time and therefore money, a few other great leaps forward in hardware have to find their way into physician offices. The advent of wireless networking makes it possible to move laptops and tablet computers from exam room, to nursing station, to office, without needing separate computers in each space. Moving the same piece of hardware from room to room saves space and costs, making the implementation of an EMR much more realistic for the physician in a small private practice. The striking advances in mobile telephone technology have now also made EMRs much more attractive by offering a way to check results away from the office with no more than a phone and a cellular connection.
Another tremendous advance for the small private practice and larger ones as well, is the server farm. It is important for physicians to again look at how other industries have incorporated this technology. Banks and e-mail providers don't bother storing their own data; they rely on secured server farms to do it. Doctors don't need to be in the IT business. Let experts handle the data and free up doctors to do their job.
With the hardware now in place, it is time for the software to harness this technology and make EMRs adapt to physicians' practice instead of asking the doctors to change the way they do things.
First, the EMR needs to be capable of “adaptive learning.” This basically means the program learns the individual doctor's practice habits with use, quickly “knowing” the doctor's most frequently seen types of patients, prescriptions, laser settings, Botox dosing, and so on. While individual doctors incorporate the art of medicine differently, there is an internal consistency for each physician. Here is where computers should shine.
Second, a program should not assume doctors document in a traditional SOAP note format. Some may want to give the patient prescriptions or do a biopsy and fill in the history later. Others want to document in real time. Still others may want their medical assistant to scribe for them in real time. The software should be able to accommodate the physician in any and all ways he or she may choose to use it.
Are We There Yet?
In the past several decades, computers have come quite a long way. If physician practices are to follow, EMR makers will have to adapt their software to the great strides in technology. Instead of blaming doctors for not adopting flawed systems, medical societies need to stand up and tell the software industry that they must do better. Indeed, even the above cited NEJM article noted that “improving the usability of electronic health records may be critical to the continued successful diffusion of the technology.”3 The time has come for EMRs to not only be great record-keeping systems but to additionally advance the efficiency of medical offices. Borrowing the language of the Intel ad, doctors would then use them because they would be “completely and totally awesome.”
Dr. Sherling is the CMO of Modernizing Medicine, a company that has developed an EMR around this technology.