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EMRs are Over-Rated: Top 11 Reasons

December 13, 2008
by If President Obama does invest a great deal in healthcare information technology and much of the money is directed at the EMR space, will it spur investment from new players
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Don't get me wrong, EMRs could be great, maybe even better than the WWW.

When I lived in the Bay Area in the late 90's, I was struck by the fact that everyone said the Internet and specifically the WWW was earth shattering, game-changing, and would make us forget all that preceded it (in 1998!). The point being that in the 90's, we could imagine the tremendous potential of the internet age, but the realities were still a far cry from that. A decade later we have come a very long way, but still more left on the journey.

Keep in mind that I'm a CIO who just went live with many EMR components in the past 2 months so I may be a bit more deluded than usual. I take tremendous pride with what our organization has done and how much better life truly is as a result of the system implementation. However, there is a part of me, that feels like some CEOs/CIOs in 1998 that read the press, spent the money, and built a fancy website for their company, and said "Now What?"

Just putting up the website didn't change the world. 1998 was the beginning: putting up a website or paying someone a lot of money to put up the website didn't change the game. However, everyone accepting that they were going to use the Internet over the period of a decade did change the world.

The healthcare industry accepting that we are going to use EMRs and President-Elect Obama affirming this direction will change the world. Here are 10 reasons why it hasn't changed yet. If you're glass is half-full, here are 10 things that will change in the next decade:

 

1. Can't Get Information Out. We've spent way too much time thinking about how we are going to get all that paper in the healthcare world into the EMR. We need to spend more time figuring out how we're going to get the information out in a cogent, actionable manner for the many clinicians that want to use it. We can't surf EMRs the way we surf the web. We need better data aggregation, handoff reports from one provider to the next, and a standard way of looking at a lifetime record.

2. Computers Don't Change People. An EMR does not in and of itself develop better communication between members of a care team. It gives them access to the same information, but it doesn't answer questions about what clinical processes and roles and responsibilities should be in a hospital. Even after an EMR, there will be clinical lapses: missed meds, empty handoffs, etc. Even worse, just like the e-mail age, the EMR will facilitate people talking less to one another (as an unintended consequence).

3. Not Enough Patient Participation. We can't type all of this stuff ourselves. We need more help from patients (who usually are pretty knowledgeable) to contribute to the information that we are collecting. Not all patients can type but a lot more have questions and are accustomed to using their PCs to live their lives. It's time that we tap into that potential in a responsible way and start interacting with our patients over the web channel.

4. The Data is Ugly. Anything that isn't billing data in the healthcare industry is ugly. There are inadequate nomenclature and data standards that are applied to content across all medical specialties. My apologies to the hard workings souls that are tackling these beasts across the industry (we need you), but we're not close enough yet. On top of that, even if we standardize the nomenclature, any 10 of my doctors will document the same clinical characteristic in 10 different locations in our EMR.

5. We Don't Know How To Drive. Our little auto industry (EMR industry) still doesn't build cars that look the same, and most of our drivers (doctors, nurses, etc.) have never seen a car before. The net effect of this is that many of our drivers drive in second gear all day, or take 3 right turns instead of taking a left turn. Vendors need to get more intuitive user interfaces, and healthcare organizations need to get better at driver ed.

6. It Doesn't Know Me & Can't Listen. If I'm a doctor that sees patients, my EMR better know who I am when I walk up to the terminal (through proximity badge or some other technology) and better listen to what I have to say (voice recognition or similar technology). Typing takes too long, and we need more innovative user technologies (the real killer Internet app for consumers is integration with your cell.phone ---what will be the killer app for users in the EMR space?)

7. They Don't Help You Drive Clinical Quality - Theoretically, if all of your patient information is in there, you should be able to figure out how well you perform certain interventions or how effective are your outcomes. However, EMRs place their current emphasis on getting stuff into the system: the goal is to be able to write any order the patient might need. The functionality is not developed to help you write the correct order for the patient. Lots of industry lip service to this goal, we need more technical innovation.

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At the risk of responding to a rhetorical question, "when no amount of additional rowing on the part of the participants can achieve the goal, new methods and vehicles are needed." Your call for disruptive innovation is right on the mark.  I heard Marion Ball talk about this a few months back and I posted this:


Does This Call for Disruptive Innovation?

I had the privilege, yesterday, to attend a presentation by Marion J Ball, Ed.D, whom most of you know, is an IBM research fellow, Hopkins Professor, Member of the IOM, Fellow of ACMI, HIMSS, CHIME, and member of HCI's Editorial Board.  

She hit on the "adding, adding, adding" problem, in describing Disruptive Innovation in the talk.  She defined DI by referencing Clayton Christensen’s definition "... a technology that brings a much more affordable and accessible product or service that is simpler to use into the market."  

Things don't get simpler by continually adding to them.  And disruptive innovation is characterized not by adding or removing from the existing paradigm, but changing it and simplifying it.  (e.g. Mainframe to PC, or rotary phone to iPhone, through several successive innovations.)

To frame it differently she shared the following quote which I'm sure resonates with all of us:


Perfection is achieved, not when there is nothing more to add, but when there is nothing left to take away.



     - Antoine de Saint-Exupery (1900-1944)


Your post brought it all back.  Thanks for asking.

Joe,

Well stated. The question to you is how do you know when you are in a row boat versus an aircraft carrier?

Jeanette,

Now that's a good idea. Please let me know what school had the program...I haven't seen a good one yet. I haven't tried looking that hard :)

-S

Suresh,
That's a great list and your points are well made.

There's an underlying premise that 'EMRs should change the world.' Like you, I also share your vision that EMRs will improve the world, for all of the quality (safety is a subset of quality), financial and access reasons we all recognize. On the other hand, there's two distinctly different paradigms to consider regarding the role of the EMR:

1) we're all in a row boat and the problem is we need to row harder (and perhaps in a more coordinated way), or

2) we're all in a row boat and we need to be on a nuclear-powered aircraft carrier, with a small fleet of cost-effective speedboats on board to handle the smaller jobs. In this paradigm, the role of the EMR is more of a powerful appliance, in an obviously larger, complex, coupled system.

EMRs are over-rated, if the problem is that we need a slightly more effective row boat. If our current healthcare delivery system is akin to that row boat, and it's operating at 80% of what's needed, then, yes, many EMRs fail to close that relatively small gap.

On the other hand, if we really want to transform our current system to address the 11 areas you highlight, something akin to the difference between a row boat and an aircraft carrier, we should expect that a great EMR will be no more than an appliance on that carrier.

I do agree with your tone that, even as an appliance, today's EMRs are ripe for lots of innovation!

As with the healthcare system I work for, there should be opportunities for current employees to explore this field of Healthcare Informatics. The key is to provide the tools to educate and train. I am one of 18 employees that received a scholarship for certification in Healthcare Informatics. Through my employer and a local college, they ventured together to ensure a program was available to make it a success. Train them and they will come! As this is quickly unfolding, I hope to find a bachelor's program to assit my further involvement in this field.

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Suresh Gunasekaran

CIO

Suresh Gunasekaran's blog provides musings from the CIO of an academic health...