Blog | Thursday, March 28, 2013

For the record

For the record: I am a geek. I love technology. I adopted electronic medical records (EMRs) when all the cool kids were using paper. Instead of loitering in the "in" doctors lounge making eyes at the nurses, I was writing clinical content and making my care more efficient. I was getting "meaningful use" out of my EMR even when nobody paid me to do it.

But now who's laughing? While they are slaving away trying to get their "meaningful use" checks, I've moved on to greener pastures, laughing at their sorry butts! It's just like my mom promised it would be. Thanks mom.

Really, for the record, I am not so much a technology fan as a "systems" guy. I like finding the right tool for the job, building systems that make it easier to do what I want, and technology is perfect for that job. I am not so much a fan of technology, but what technology can do. Technology is not the goal, it is the best tool to reach many of my goals. There are two things that measure the effectiveness of a tool: Is the tool the right one for the job? Is the person using the tool properly?

So, when answering the question I posed at the end of my last post, what constitutes a "good" EMR, I have to use these criteria.

How is technology the right tool for the job? The job I seek to do is not what EMR's are designed for: documenting health care. I want a tool to help me give care. I can afford to focus on giving better care since I am no longer paid to document, which is what the health care system demands of doctors. I spent the past 16 years using a documentation tool for care, which is definitely a mismatch.

What then would a care tool look like? Here are the things I think are most important for good care:

1. Communication over documentation

While data gets all the attention of IT vendors, health executives, and government drones, it is the communication of that data that constitutes good care. One of my first goals in my new practice is to use whatever tools possible to enable that communication. Standard health care only allows communication in the exam room (although many patients would say that doctors are so focused on documentation that they don't listen there either). Between office visits there is virtual silence from the patient, as if their life is not happening during that time.

I've considered making bumper stickers that say: "My doctor answers my e-mail" or "My doctor answers the phone," with my logo and web address underneath. This is effective because of the insinuated truth that most doctors don't do either. The system dictates this, but good care says otherwise. My patients have been delighted when I answer questions, view the spreadsheets they fill out, and interact with them on a daily basis. It's communication, and tech makes it much easier.

Documentation is OK, as long as that documentation centers on the communication of data, not just the data itself.

Yet even I use the term "medical record," which refers to a static collection of data rather than a tool to allow that data to be used well. Any good health IT system must not simply document the communication, but must enable that communication as to happen easily as possible. This means both getting information from my patients and putting it into their hands. This is why another central goal of my practice is to give patients access to their records. Too much of patient care is done blindly, not knowing what care has been done, relying on the patient to re-recite their medical history. With the proliferation of mobile technology, my patients can bring their medical record with them wherever they go. This, in turn, enables better communication with other providers.

2. Organization of data

Walking around with a computerized stack of paper, however, is not all that my patients need; they need the information to be organized. This is another of the strengths of IT. An astute commenter on my last post gave a link to a TED talk on the beauty of data visualization, which shows how organizing and presenting data in the right way can make dry data tell rich stories. I want an EMR that shows me a timeline of the patient tagged with their symptoms, medications, lab results, vital signs, and any other pertinent data I want to see. What is the relationship of exercise to your depression? Did that back pain start after you added that medication?

The point of organization is to see through the extraneous to see the meaningful. It is, in essence, another part of communication. As I listen to a patient's story, I ask questions and bring out important details they may have missed, and ignoring that which I know is not significant. This is what makes a good diagnostician, and the ability to this with the volumes of patient data is what would allow IT to improve care.

3. Collaboration, not ownership

The world of health IT is obsessed with something called "data ownership." This is kind of crazy, as data is information, and information is fluid. How do you "own" information? If I learn a fact, do I "own it?" If I possess a book, does that make me the owner of its ideas? The wonderful world of HIPAA and the threat of identity theft has bolstered the cause of "ownership." Unfortunately, communication of ideas is diametrically opposed to this concept. IT must not be about building walled gardens of data, but about collaborating with that data for the sake of patient care.

I first heard of the term, collaborative health record from Dave Chase (the guy who first told me about my kind of practice), and I really like the concept. The idea is that the ideal patient record is a collaboration between the patient and the caretakers. Patients know things I don't: what meds they've been taking, how they feel, whether they are married, are smoking, or if they had measles as a child. In fact, if you look at a typical note in a patient chart, the majority of the information is originally "owned" by the patient. So why not let them take care of those parts of the record? Why not let them update when they've been to a specialist and had their medication changed? Better yet, why not have the specialist take part in this too, collaborating to make sure the patient got the message correctly?

Why, in fact, do I need to re-create what the patient could do better than me? Why not just look at what they've done instead of transcribing it into "my" record?

This sounds suspiciously like a wiki. What resource on the internet gives useful (albeit sometimes inaccurate) information in a format that elementary school students understand? Wikipedia. Isn't this a better way to organize patient data than a typical EMR?

4. Easy does it

In considering what I need from IT to give patient care, there is one more thing I need – something that is clearly lacking in most EMR systems: ease of use. I should have seen the writing on the wall when my EMR vendor insisted I pay for 4 days of onsite training before I could use their system. I don't want to learn a new language, and my patients want it even less. Just as a medication a patient cannot afford is useless, a technology a patient won't use is also useless. Tech can go either way on this: either making difficult tasks easy or making simple things complicated. This is where Steve Jobs was right: design simplicity.

I don't want my patients to have a separate log-in for each part of their care. I want a single sign-in and a uniform experience. I want an app that they press which pops up options to "refill my meds," "contact my doctor," "update my record," and "look up a result." I don't want them to need to own certain software or download files. It's got to be easy and well-designed.

Putting it together

So in thinking about this wish list, it occurred to me that there is one company that could deliver all of the goods here: Google. Apple and Microsoft have many of the same tools, but they are far more proprietary in their approach. If I share a spreadsheet with a patient, I don't want to have to worry they own Excel. If I want to do a video chat, I don't want to have to consider if they've got a device that can do FaceTime. Google does e-mail, spreadsheets, video chat, groups, web pages, organizes data, and has lots of cat videos to boot. And all of these services are easy to use and free. Most of them are free.

So should Google get back into health IT? Didn't they already try health IT and fail? Ah, but it's not just having the right tool that is important, it's knowing how to use it.

So, Google, if you really are interested in changing the world for the better, you know where to find me. I suppose I'd be willing to talk.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.