Work continues at UT Southwestern Medical Center University Hospitals in our journey towards an electronic medical record. Implementation teams continue to make progress on the application builds of the pharmacy, anesthesia pre-operative assessments and emergency department systems. Though we've had some setbacks on our projects, we continue to be hopeful that we are on track for the upcoming go-lives.
November marked the first month of heavy physician involvement in the design and implementation of the EMR. Led by our chief medical officer and vice president of clinical quality, we have physician workgroups addressing physician order entry and results review. Both groups have made significant progress on their respective projects, but this work has re-opened some longstanding wounds in physician relations with our IT department.
The most interesting topic of contention has taken me back 10 years. In 1998, I was facilitating a meeting on EMRs with several physicians at a major industry conference. In this meeting, several IT professionals were explaining the benefits of the EMR system for physicians.
After they went through the laundry list of benefits to the physicians, one physician raised his hand and asked a question, “Will this save me any time?” The IT professional, with a look of complete candor on his face said, “To be honest, this system will not save you any time, but it will force you to do better, more thorough documentation of the clinical care that you deliver.”
The physician looked at the group and responded, “You want to me spend over $20 million on an electronic medical record, but it isn't going to save me time?”
IT professionals have had some form of this conversation with clinicians in conference rooms across the country for many years now. Each conversation most often ends with the IT professional confessing that regardless of best intentions, clinicians should never believe that an EMR will save them time: an EMR leads to better care, not faster care. It is this simple conversation that draws a wedge between every IT professional and clinician on an EMR project. “Good” IT analysts know not to promise time savings; “good” physicians know not to expect time savings.
UT Southwestern Medical Center is undertaking an active effort to help physicians save time through the use of an EMR. We're involving physicians in developing the process and technology solutions that will help us achieve this goal. We know that there is no single silver bullet, but rather a whole series of little, often unrelated items that will allow physicians to save time. The top 10 efforts are detailed below.
1. Charting by exception
Charting on a blank screen may well be the single greatest barrier to fast use on an EMR for physicians. Picking from endlessly long drop down lists or constantly having to search for terms ranks as the second and third greatest barriers. The key to an EMR user interface is the ability to click and type only as needed on a given documentation form. Most often this requires specialty-based customization and pre-loading to ensure physicians have “just the necessary items” in front of them during a clinical encounter.
2. Presenting relevant history and previous results
Excessive scrolling and the need to switch between screens during clinical documentation is another often-cited physician complaint. Typically, during order entry or clinic note documentation, the provider wants to view previous period lab or radiology results, which often requires opening a new window or scrolling. The ability to have extra screen space either through dual-monitor workstations or innovative user interface design that shows previous results within the primary workflow are viable solutions.
3. The PC
The computer itself has become “Public Enemy #1” for many physicians in their use of an EMR. Quite often, traditional desktop PCs are placed in locations that require the clinician to turn away from the patient to document care. In addition, PCs are often attached to equipment carts and rolled from one location to another. This too can be cumbersome for many providers. Some organizations have rushed to use tablet PCs and PDAs as alternatives to these traditional pitfalls; however, these technologies have problems as well (PDAs are too small, tablets do not work well with most major EMR vendors). At UT Southwestern, we are actively using laptops to bridge many of these gaps, giving each clinician a wireless laptop that can be used to document care. We've supplemented this with PCs at most nursing and physician stations.
4. Easy to understand nomenclature
Sometimes the simplest things can cause the greatest frustration. Many physicians' impatience with an EMR system is finding the right order in a drop down menu. This is especially true when ordering laboratory and radiology services that can be named in different ways and be part of multiple different hierarchies (i.e. should the dropdown for radiology exams be first grouped by modality, then body part, or vice versa?). Similarly, when a test is resulted, physicians often struggle to understand in which section the result will return and whether it will be comparable to historical studies. Standardizing terminology and nomenclature and educating physicians on this structure is crucial to harmony in ordering and resulting.
5. The login and the first screen
Simply put, physicians want to log-in quickly and get to work. It is crucial that sign-on processes be as simple as possible (including smart card or proximity badge authentication) and immediately open the physician to an action-oriented first screen. It is important to spend time up front giving physicians access to most-used functions at initial login.
6. Fewer clicks
The majority of applications today use a similar graphical interface in the EMR space. However, most EMR vendors have taken a “more is more” attitude with their applications to ensure that they are comprehensive in their ability to meet clinician needs. Unfortunately, this has led to crowded screens, much scrolling and numerous tabs. Physicians are frustrated because the EMR, by its nature, requires the use of keyboards for some free text functions, and additionally the mouse clicking required is also significant, which leads to switching back and forth. Most physicians would prefer to have their work done on a few, un-crowded screens, with the mouse clicking segmented to one series of activities, and keyboard to another segment.
7. Locations to access
Physicians work across multiple settings and want efficient access from all locations. It's important to balance this goal with the protection and safeguarding of patient data (physicians can't store clinical data on PDAs or laptops, lest they get stolen). However, it is important that physicians have access within the hospital, from their offices, and from their homes to stay connected to patients in the hospital and monitor the progress of their patients. It's important that over time, alerts and key clinical indicators can be delivered to wireless PDAs and phones. This technology has not matured, but the demand from physicians has. Most recently, regional transplant services have begun to notify surgeons of candidates through wireless PDAs. This trend will only grow.
8. Relevant reminders/alerts
After a few years of using an EMR, it is easy for the average user to get overwhelmed by the sheer volume of data that is stored within it. Virtually every results screen, every notes screen, and previous history screen can have numerous studies and results available. It's crucial that time and effort is placed at the beginning of the process to ensure that reminders and alerts are configured to draw physician attention to the results and adverse events first. It is critical not to overdue this and fatigue physicians to the point that they ignore important alerts.
9. Smart preference lists for common activities
It is important that physician behavior is monitored on a consistent basis and that order sets and preference lists are updated on a continuous basis. Physicians practice patterns must be accounted for and pre-built to facilitate efficient ordering and documentation within the system. Many organizations rely on the implementation team to get it right on go-live day; other organizations require physicians to request changes. For success, this must be an ongoing process with dedicated support resources.
Physician usability of the EMR will not change overnight. However, it will re-emerge as one of the top drivers of enterprise EMR efforts.
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