An Open Letter About Electronic Medical Records

Last year I wrote a critique of the electronic medical record (EMR) my organization has adopted.  I came down pretty hard on its user unfriendliness and overall clunkiness, and expressed dissatisfaction with the office note that served as the final product.  In the ensuing months since I published my opinion I've come to be even more bothered by the weaknesses of not just our EMR, but the EMR landscape as a whole.

In doing a little psychoanalysis on myself I've come to the conclusion that my strong feelings about the shortcomings of EMR arise not from my disdain for the concept, but rather from my love of the idea of EMR and my disappointment that it can't live up to its potential.  It's like going out to a fancy restaurant where a great chef whips up a meal of the finest ingredients but which, in the end, tastes like cardboard.

But, as my grandmother always said, if you can't say something good don't say anything at all (of course nobody's grandmother ever says such things, but the attribution makes the aphorism sound more folksy).  In reality, my grandmother was a little more to the point: "If you can't write a blog on what the future of EMR needs to look like, then give up writing all together and get back to work.  And go fetch me some BenGay and prune juice while you’re at it."

So, in honor of my prescient grandmother, here's a letter I've written to all the EMR programmers, present and future:

Dear computer programmers and EMR developers:

Your product stinks.  The whole world of medical communication took a great big nosedive the moment you and your binary code inserted yourself into the business of medicine.  That doesn’t mean you can’t redeem yourself—you can.  Here’s how.

Rule No. 1: Remember why we keep medical records in the first place. Contrary to what you might think, the purpose of doctors’ notes is not primarily to enhance reimbursement or comply with government regulations; it’s to communicate.

Years ago doctors wrote notes to pass along information to their colleagues and to scientifically track the progress of their patients.  In the ensuing years we’ve lost the flavor of these original records—we no longer invest time and effort into describing our patients and their ailments with the literary élan of our predecessors (“This is a sad case of an engaging youngster, doomed to an existence as a chimney sweep and chronically disheveled but of cheerful countenance, who has developed a painless mass . . .”).  Doctors used the space in the record to chronicle their musings on the patient’s condition and to jot their analytical insight.

Medical records continue to serve this purpose, but only nominally, as outside forces have required the clinical chart to fill other roles.  We now have to add irrelevant information to satisfy billing requirements, document our discussions of risks to limit our malpractice liability, and insert scores of redundant data to assuage layers of government oversight.

So, despite the fact that your product has to address all these new demands, you still need to focus on creating a program that has communication as its primary function.  In other words, we don’t want any more notes that look like they were thrown together by a room full of monkeys on typewriters.  We want to go back to the coherent communication of the past.

Rule number two: keep it simple.  I have long maintained that computers have the ability to streamline the medical care environment and make all our lives better.  Right now, a clinic with an EMR in place runs slower and less efficiently than an office that sticks to the old, hand-written chart.  This doesn’t have to be the case.  Automation has enhanced productivity since the days of Eli Whitney and his cotton gin (whatever that is—some type of alcohol?) and there’s no good reason you can’t produce an EMR that actually makes me a more efficient doctor.

Rule No. 3: The product has to benefit patients. If our EMR doesn’t help us provide better care, then I suggest you quit the world of medicine and go back to programming video games and playing Dungeons and Dragons.  Take a hard look at the patient experience and figure out ways to make life better for them.  Focus on shorter waiting times, more comprehensive preventive therapies, and decreasing the risk of medical errors.

Here’s my list of what I’d like to see in an ideal EMR (Warning: the following discussion is mind-numbingly boring to anyone not in the medical field.  I strongly encourage you stop reading here and go back to watching cute cat videos on YouTube.):

• Power up quickly.  Why does my EMR require several different log-ins and take minutes to load up, but my iPad applications can start up in nanoseconds.  There are probably a million reasons you’ll cite why this has to take so long, but with the current state of technology I don’t buy any of them.  Simplify the portal.
• Go truly paperless.  My experience is that the more “paperless” we go, the more paper we end up using.  Figure out what gets printed and find a way to incorporate that into the program.  Trees are in rare supply but there seems to be no global shortage of electrons.  You never see stacks of paper or shred boxes on the sick bay of the USS Enterprise, do you?
• Store data on the cloud.  I want access on my computer, iPad, smart phone, and even my toaster (once I get one of those fancy internet toasters).  Give us biometric access so that we don’t need a gauntlet of logon IDs and passwords.
• Give patients access to their own records.  Each of our customers should have immediate and unrestricted connectivity to their data.  The moment I finish an office note it should appear in some database that patients can easily review.
• Fix the voice recognition software.  I know the technology is out there.  Find some way to allow us doctors to mumble our way through a note and have it correctly translated into complete sentences, commas and all.  For years little old ladies have sat in darkened cubicles correctly transcribing doctor dictations with only rare errors—can’t you write computer code that rises to that level?
• Start using artificial intelligence (AI).  If I can have a discussion about philosophy with woman name Siri on my iPhone, why can’t my EMR be smarter than it is?  I want a system that automatically schedules a follow-up appointment when I say “I’ll see the patient back in a month” and will send prescriptions to the pharmacy when I dictate “let’s start atenolol 50mg daily.”  I shouldn’t have to expend a single additional calorie re-entering commands into a system that can’t think on its own.
• Provide feedback.  As it stands, my EMR does nothing to help me improve the care I provide patients.  I want a system that screens all my patients and flags those whose care has deficiencies.  Figure out whose blood pressure has been inadequately treated, who needs an updated blood test, which patients should be screened for peripheral vascular disease, and so on.  Medical science has produced reams of algorithms that allow us to provide better preventive care—they’re just never incorporated into our computerized system.  I want to know that my EMR is helping me provide the best care possible.

Someday there will be a Steve Jobs of the EMR world who will come along and produce a system that listens in on my office visit with the patient, uses voice recognition and AI to produce an extremely accurate summary of the discussion, and schedules all necessary tests and medications based on what I explain to the patient—all without me having to even interact with a computer keyboard.  The note will be instantly dispersed to the patient and all other caregivers.  The program will suggest any useful therapies that I may have missed and provide educational resources to the patient based on the subjects discussed.  And, of course, it’ll hit all the high points needed by the coders and Medicare overlords.

When this happens it’ll put every other EMR out of business; because, finally, we’ll have a system that actually helps us rather than hampers us.  If you can do this, dear programmers, then I promise I’ll write a three-page blog praising your name and extolling all your zeros and ones.  And, most of all, I swear to never again joke about Dungeons and Dragons.

Sincerely, and with hopeful optimism,

Dr. Van De Graaff