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October 6, 2009
by Joe Bormel
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There's a tremendous irony about ARRA/HITECH. It comes in the form of non-goals.

Along with the clearly identified need for EHR technology to improve our healthcare delivery system came some concurrent observations, i.e. need for the current EHRs to improve. A recurring, big observation was that the user experience (the GUI, the number of clicks, the ease of use, the intuitiveness, etc.) of all EHRs, commercial, homegrown, and OSS offerings, were way behind that of the user experience for mainstream commercial applications. Many consumer Web sites are an absolute pleasure to use, and highly effective. Google, Amazon, and others will give you what you want, in addition to what you actually ask for. They'll correct your misspellings and make you aware of relevant options, based on the experience of other users with apparently similar intentions. (This is accomplished, of course, with zero human build work, and maintained in real time.) They've transcended a focus on automated basic workflows and associating decision support with process automation. They prefer to collect (with opt-out, of course) personal information. What do you commonly do? How do you seem to prefer to do it? There are often three or more options for how to get from here to there. If you try something reasonable, it's been thought through and will often work. If not, you're likely do get a "did you mean ...?" option. Most of us, as a result of these modern consumer user experiences, have more books (from, and perhaps many unread books, throughout our homes, because browsing and one-click ordering are so darn easy.

Modern consumer user experiences are a great thing. We can read and write (interact) news through newspapers, online everything, and of course, blogs like those at HCI. Wouldn't it be great if we had similar fluency with our healthcare information? As nurses and doctors, of course. And as patients, of course.

Instead, what we experience today is considerably more dated. My physician, for example, recently sent me the results of

my labs. He went out of his way to personalize the results with a handwritten note. That's nice. He's on one of the most popular ambulatory EHRs and has been for over five years. For at least three years, his group has had the most sophisticated ePrescribing solution integrated with its EHR. Here's where things apparently break down badly, relative to a consumer experience. The lab results are apparently not integrated, as suggested by the lab report he sent. The report is almost completely naive to my problems, medications, allergies and key clinical trends. Is my LIPID PROFILE getting better or worse? What, if any therapies are concurrently associated with these therapeutic results. Not clear from the printout or the handwriting. The note was subsequently scanned into the EHR. Again, this is one of the most automated practices in my area. They made the EHR investment years ago, and have stayed up to date with their releases.

With ARRA/HITECH, all vendors, both ambulatory and inpatient, have had an extremely strong incentive to stop developing according to their roadmaps, leading in part to more consumer friendly features like showing new lab results in the clinical context of problems, medications, and key trends. Most readers appreciate that this suspension of innovation is necessary and ultimately a good thing in order to gain the benefits of certified products and establishing a meaningful use threshold. That said, the work to deliver the consumer grade experience has clearly been put on the back burner.

Consumer-grade EHR experience Cool prototypes and ports to the iPhone are great and necessary. Keep them coming.

That said, here's what I'd like to see:

For the patient: When I get a snailmail, fax, or email from my physician, like the lab results image above, I want the results in explicit context. I don't just want the LDL and total cholesterol. I want the most recent value, next to the relevant summary. So, "Before your most recent change, your cholesterol was 400 while taking Lipitor 10 mg a day. As a result of going to CRESTOR 20 mg a day, your total cholesterol is 140. The liver and muscle related labs show no evidence of bad side effects. The recent Jupiter and Saturn clinical trials suggest that you're now on course to live forever. Let's repeat these labs in 6 months."

Of course, I'm being a little entertaining here, but I'm serious as well. All of that information could be assembled for the physician to review, and should be. Anything less would be less reliable. Dare I say less safe?

When my parents ask me to review their lab work, today it's an unreliable process. Previous labs? Yes but not always. What drugs were they taking? For the current results, yes. Reviewing the labs from 6 months ago, dicey. Five year trend of PSA results? Never.

For the doctor: When I get a lab result back as a doctor, I need the same things, and a bit more. For example, lots of patients are on the blood thinner Coumadin. When their labs come back, there's a result called an INR. The goal is to adjust their medication to get the INR to into some range, say between 2 and 3.

What could the consumer-grade experience be in an EHR, for the physician if the result comes back at 10? How about this:

  • First of all, the INR comes back, clearly in the context of prior INRs and dates of those INRs. As above, those results are paired with the dose of Coumadin the patient was on that produced those INR results. And, as above, the lab and other results that capture potential toxicities are also shown, passively, without the physician needing to 1) think about it, 2) navigate elsewhere, 3) keep all of that in her/his head, and 4) carry that forward reliably into the next action.
  • Then, it needs to be a one-click process for the physician to call the patient (phone, email if clinically appropriate, video conference, IM, or a HIPAA-appropriate tweet.)
  • A documentation template, summarizing the above clinical condition is, of course, pre-populated in that evolving note.
  • The note makes it easy and reliably to:
    • document that the patient reports having no related symptoms
    • prescribe the appropriate antidote at the appropriate dose if desired (pre-screened, of course for allergies, dose-range, etc.)
    • document that the patient was informed, denied symptoms, was advised regarding behavioral restrictions (e.g. no Disney motion rides today), and follow-up instructions.

Doing the above, either for patient notification or physician workflow today would be a 15 to 30 minute process. As we all know, using today's EHRs, these activities occur, at best, 50% of the time with a reasonable degree of completeness. If you believe in Clinical Bundles - a cohesive unit or set of things, all of which should happen , this percentage probably falls to 10%.

In my mind, even worse, is the degree of build work necessary to achieve this capability. Smart readers will know that many EHRs can create the experiences outlined above. The build work to "make it so" is measured in the tens of hours. The result, capable EHRs are used as blunt instruments. Clearly, a non-consumer grade experience.

I think this disciplined prioritization (i.e. the current certification and MU process) would be healthy if we were talking about it in public. Hence, "Non-Goals" statements. Some people of course are being very candid and honest with HITECH. Watch

Anthony Guerra's VIDEO BLOG and

download his paired slides. But Anthony is the exception. Many policy makers are simply disingenuous. They encourage rage by suggesting CIOs think the current, state of the art EHR is great. Instead, they should follow the lead of economist Michael Mandel, below, that ARRA needs to be part of a multi-phase deployment. And, we acknowledge that consumerization cannot and should not be in phase one.

On the technology side, achieving the rich, consumer-grade experience in the Web world requires technologies like Adobe's popular Flash. Another related emerging Web technology, WebKit, is a layout engine that supports advanced ways to render Web pages to create a richer user experience. In reading the main WebKit page (insert link), I saw a clear list of goals. But perhaps more importantly, it was followed by a list of Non-Goals. What a wonderful way to set clear expectations!



The above goals are a lot to bite off, and there are a few points that arise occasionally which we consider out of scope for the project.

WebKit is an engine, not a browser.
We do not plan to develop or host a full-featured web browser based on WebKit. Others are welcome to do so, of course.
WebKit is an engineering project not a science project.
For new features to be adopted into WebKit, we strongly prefer for the technology or at least the use case for it to be proven.
WebKit is not a bundle of maximally general and reusable code.
We build some general-purpose parts, but only to the degree needed to be a good web content engine.
WebKit is not the solution to every problem.
We focus on web content, not complete solutions to every imaginable technology need.

There's an interesting parallel to this one-two sequence of EHR policy reform. One, standardize the platform, then two, innovate on the experience. In healthcare economic reform, according to

BusinessWeek chief economist Mike Mandel,

you've got to solve the healthcare coverage problem before you address the cost problem. Otherwise, you'll just have massive cost shifting resulting in unmanageable coverage worsening. The Dems are better politically positioned to take on coverage; the Republicans, the cost. That's according to Mandel. If there's a similar fate for EHRs, the Republicans will be the party to bring consumerization to EHRs, since this must be a non-goal as we focus on basic coverage. That's certification and meaningful use. December, 2009. Coming to a state near you!

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