As part of my ongoing writing about what people are starting to call the EHR Backlash, I started to think about the shifting tides of EMR documentation. One of the strongest parts of the EHR backlash from doctors surrounds the convoluted documentation that an EMR creates. There is no end to the doctors who are tired of getting a stack of EMR documentation where 2 lines in the middle mean anything to them.
Related to this is the physician backlash to “having to do SOOOO many clicks.” (emphasis theirs) I still love the analogy of EHR clicks compared to playing a piano, but unfortunately EHR vendors haven’t done a good job solving the two things described in that article: fast predictable response and training.
With so many doctors dissatisfied with all the clicking, I predict we’re going to see a shift of documentation requirements that are going to need a full keyboard as many doctors do away with the point and click craziness that makes up many doctors lives. Sure, transcription and voice recognition can play a role for many doctors and scribes or similar documentation methods will have their place, but I don’t see them taking over the documentation. The next generation of doctors type quickly and won’t have any problem typing their notes just like I don’t have any issue typing this blog post.
As I think about the need for the keyboard, it makes me think about the various point of care computing options out there. I really don’t see a virtual keyboard on a tablet ever becoming a regular typing instrument. At CES I saw a projected keyboard screen that was pretty cool, but still had a lot of development to go. This makes sense why the COWs that I saw demoed at HIMSS are so popular and likely will be for a long time to come.
Even if you subscribe to the scribe or other data input method, I still think most of that documentation is going to need to be available at the point of care. I’ve seen first hand the difference of having a full keyboard documentation tool in the room with you versus charting in some other location. There’s just so much efficiency lost when you’re not able to document in the EMR at the point of care.
I expect that as EMR documentation options change, the need to have EMR documentation at the point of care is going to become even more important.
Accessibility of Charts
The second EHR benefit is similar to the Legibility of Notes benefit in that it is easily forgotten as a benefit to EHR and it can be hard to quantify the value of the benefit in dollar amounts. Plus, it is really easy to see how nice accessible charts are to an organization.
There are a number of ways to look at the EHR benefit of accessible charts. The most obvious one is when you think about the number of times a chart has gone missing in a clinic. In most cases, the chart isn’t really missing. It’s in the clinic somewhere, but no one can find it. Remember all those special places that a chart could hide: exam room, physician’s desk, front desk, nurse’s desk, lab sign off box, physician’s car, hospital, physician’s home, etc etc etc. Oh yes, I didn’t even mention HIM not being able to find the chart because someone (probably someone other than HIM) misfiled the paper chart.
I’m sure most HIM people who read this will have a visceral reaction. I’m sure many are likely thinking, “But we do an amazing job keeping track of all those paper charts.” I agree with them 100%. A good HIM person has done an amazing job keeping track of paper charts. It would be 100 times worse if they weren’t there. The problem is that if a dozen people are using the paper chart, the reality is that charts are going to go missing.
Now think about the concept when it comes to EHR. None of those lost chart locations exist. The nurse can’t accidentally take the chart and forget to file it. The doctor can’t forget the chart at home or in his car. No one can misfile the chart.
Think about it. An EHR solves 100% of the problem of missing paper charts.
Besides misplaced paper charts, the idea of chart accessibility is an important one when you consider the idea of accessing an EHR remotely. Even if you use a less than ideal remote desktop solution, a physician can access an EHR anywhere they have an internet connection. For web based EHR, you get exactly the same experience accessing the EHR remotely as you would in the office.
I’ve heard horror stories (at least their pretty horrible to me) of doctors getting late night patient calls which require them to get dressed, go into the office, open the medical records room to access a patient chart. With an EHR, that same workflow has the doctor booting his computer and logging into the EHR. This doesn’t apply to all doctors, but for those that do it’s a dramatic difference.
The biggest fear I’ve heard from doctors in this regard is they often equate chart accessibility with their accessibility. The argument goes that if they can access the chart 24/7, that it also means they have to work 24/7. I think this is a myth that doesn’t match most realities. Just because you had a key to your office and could go and work on paper charts 24/7 doesn’t mean you had to do it. The same is true with remote access to EHR. You choose when is appropriate and important to access and work on the EHR and when not to do so.
The key difference between EHR and paper charts is that when you do want to access a patient’s record remotely you have that option available to you. That doesn’t mean you always have to do so, but it is nice to have that option available.
When talking about EHR accessibility, I think also about the landscape of connected mobile devices (smart phones, tablets, etc). All of these devices are connected to the internet at all times and could provide a doctor access to their EHR almost anywhere in the world. Try doing that with paper.
The problem here is that most EHR don’t do well on mobile devices. Remote desktop from a smart phone or tablet works, but is a pretty terrible user experience. A native mobile app provides a much better experience for users, but we’re still in the early days of EHR mobile app development. As this matures, the accessibility of charts will become an even bigger EHR benefit.
Another week has passed and we’re back with some of the interested EMR and Health IT related tweets this week. Tomorrow I’m flying to AHIMA in Chicago. It’s setting up to be a really great event that should produce some really interesting content. More on that in future posts. Plus, I’m bringing a camera with me and hoping to get a lot of the people I talk with on video.
Now on to the EMR tweets!
First heard @doctor_v talk about EMR & Social Media integration 4 years ago when I met him. It’ll happen someday #MedX
Most doctors cringe at even the thought EMR and social media in the same sentence. This is a huge barrier for any EMR to integrate with social media sites. Although, I agree with Dr. Sevilla that it’s going to happen some day.
This article was pretty terrible and felt like the journalist was trying to sell DrChrono. Who knows, maybe the were. Although, the headline and their conclusion is pretty insane. Their logic in the article is that because a large percentage (62%) of physicians use a tablet for professional uses, then it’s the perfect solution for EMR. Talk about a stretch. Maybe the tablet will eventually become the EMR device of choice, but it hasn’t happened yet. It’s fine for consuming content, but not so good at entering data.
As I was thinking about the radical invention of something called paper, I realized that we’re really quite spoiled by paper and its amazing benefits. Let me just list a few of the radical benefits that paper provides a doctor using a paper chart.
* Immediate response to pen – Yes, tablets and styluses are getting better, but there’s nothing like the instant satisfaction of putting pen to paper and seeing the ink spread across the page. Sure, the pen runs out every once in a while, but that’s generally pretty rare. A nice pen just flat out works with an immediate response in the exact location you want something written. There’s no calibration needed. You just pick it up and start using it. It’s beautiful.
* Never a delay when flipping pages – Think about the beauty of paper’s ability to flip between pages. When I turn a page I get an immediate response to that flip and see the desired result (a new page) immediately. I’ve never seen an hour glass when flipping between pieces of paper. I’ve never had a page partially load and need to refresh. Paper has the unique ability to flip pages with instant display of the next page.
* Instant On – Speaking of instant, paper charts are the true epitome of “Instant On” technology. Computers are getting better at making boot times fast and computers turning on quickly. However, anyone who regularly uses a computer knows all the screens you have to see as your computer boots up. A paper chart is beautiful in its ability to immediately be available for you to work. It has true Instant On capabilities.
* No training needed – Ok, maybe this is a stretch of a title. There is no training needed for paper, because since elementary school we’ve been taught how to write with pen and paper. The ability to write is near universal thanks to training in doing so since we were children. You hand a new doctor some pen and paper and they can start documenting their visit. No login or password required. No needing to know how to access Citrix so you can open the chart. Just hand them the chart and a pen and they start charting.
* Multiple page view – The display area of paper is so expandable. If you need a dual monitor dual page view of the paper you just slide it open. If you need a quad page view, you’re only limited by the amount of desk space you have or you could even move to the floor if needed. This easy to manage multi page view is powerful since it’s quite often that you want to see multiple pages at the same time.
* Fast page switching – Take a paper chart and watch how fast you can switch back and forth between pages of the chart. I call this “thumb in chart mode.” With 5 fingers you can even instantly “bookmark” up to 5 locations in the chart which you can switch to and back very quickly with zero load time.
* Flexible to an infinite number of documentation methods – Does paper support the SOAP format? Yes! Does it support every specialty? Yes! Paper has the ability to morph to every medical specialty’s documentation needs. In fact, it can easily be adapted to a different documentation method for every doctor within every specialty. It’s designed so flexibly that there really are an infinite number of documentation methods it can support.
* Easily supports text and graphic input – Oh the beauty of paper. In the same input area you can easily add text or graphics. In fact you can easily link the text and graphics in whatever way you see fit. Some might prefer to write male or others might prefer to draw the universal symbol for male. It’s completely extensible to text or graphics in every area of the page.
I’m sure there are other areas where paper spoils us that I’ve missed, but this is a good start. Hopefully you’ll add any areas I’ve missed in the comments.
Watch for future posts in my “Healthcare Spoiled” series.
I hate to keep bashing Silicon Valley, since I’ve come to think that it’s venture capitalists, not tied to one particular region, who are the ones not “getting” healthcare. That said, we got a bit more overblown hyperbole coming out of Northern California this morning from drchrono.
The Mountain View, Calif.-based company, which likely is correct when it says it created the first EHR that it native to the iPad—and a free one at that—announced today that it has received an new round of $650,000 in seed funding from the VC community. (Congratulations on that.) Drchrono today also introduced OnPatient, an iPad app that replaces the hated clipboard and paper form for taking patient history at the doctor’s office. Here are the details, from the drchrono press release:
drchrono Launches iPad App to Replace Paper-Based Check-In at Doctor’s Office; Closes Additional $650,000 in Seed Funding
Free OnPatient App Digitizes Patient Waiting Room and Integrates Seamlessly with Electronic Medical Records
Mountain View, CA – August 18, 2011 – drchrono, the company modernizing healthcare through a free Electronic Health Record (EHR) platform on the iPad, today announced a new patient check-in app which replaces the traditional paper check-in process in the physician waiting room. OnPatient is an app that can be downloaded to the iPad for free and integrated into a medical practice as a stand alone onboard app. The patient check-in app also seamlessly integrates with drchrono’s Meaningful Use-certified iPad EHR.
On the heels of the OnPatient product launch, drchrono recently closed an additional $650,000 in seed funding from prominent start-up investor Yuri Milner, founder of DST Global, and venture capital firm General Catalyst. This follows $675,000 in seed funding from General Catalyst, Charles River Ventures, 500 Startups and angel investors, previously announced in July.
“The OnPatient check-in app digitizes the waiting room and eliminates significant barriers to mass adoption of patient check-in technology by leveraging sophisticated iPad technology. Proprietary check-in hardware is prohibitively expensive and integration with existing EHR systems is too complex,” said Michael Nusimow, co-founder and CEO of drchrono. “We designed the OnPatient app to be intuitive for both physicians and patient users to create a better patient check-in experience.”
OnPatient is a full-featured app with customizable templates that enable physicians to eliminate paper forms and clipboards in the waiting room. There are no contracts or monthly fees; the only hardware investment is the iPad itself. Upon download, the OnPatient app allows patients to:
Complete family medical history and demographic information
Complete insurance information
Snap a profile photo
Sign the HIPAA consent form with a digital signature
The touch screen interface is user-friendly and the information auto-populates directly into the drchrono EHR platform. On subsequent visits, patients do not have to complete duplicate forms—they need only review their information and make any necessary changes on the iPad. OnPatient meets all industry security standards, ensuring the privacy and safety of patient data.
For more information on drchrono and the OnPatient app, please visit www.drchrono.com.
drchrono focuses on Apple’s iPad and cloud computing to build a better healthcare experience.
They offer a free EHR platform built on the iPad that is Meaningful Use certified. drchrono is also the first iPad EHR to implement real time clinical speech-to-text. drchrono handles everything a doctor needs to run their practice, including medical records, electronic prescribing, medical billing, and patient management. For more information, visit https://drchrono.com
The drchrono iPad EHR is 2011/2012 compliant and has been certified by InfoGard Laboratories, an ONC-ATCB, as a complete EHR in accordance with the applicable certification criteria adopted by the Secretary of Health and Human Services. This certification does not represent an endorsement by the U.S. Department of Health and Human Services or guarantee the receipt of incentive payments. drchrono version 9.0 was Stage 1 certified on June 3, 2011. The ONC certification ID number is IG-2492-11-0083
What got me was the claim in the e-mail that accompanied the press release. “Today, drchrono, a hot Y Combinator start-up focused on Apple’s iPad and cloud computing to build a better healthcare experience, announced OnPatient, a groundbreaking app that digitizes the medical practice waiting room,” the message started. This was the same claim that drchrono included in a media advisory earlier in the week.
Sorry, there is nothing “groundbreaking” about software that collects medical history electronically and automatically populates an EHR with this information. Instant Medical History, a program from Primetime Medical Software, Columbia, S.C., has been doing this for years. Though it is primarily a PHR vendor, NoMoreClipboard.com‘s name betrays one of its products, a patient portal for medical practices that collects patient history online. ePatientHistory.com is similar.
No, IMH does not have a native iPad app, but it’s worked on tablets going back to the bulky Windows tablets circa 2003, even if few customers actually chose that option. NoMoreClipboard.com is Web-based, which means it’s accessible from any device with a Web browser such as, say, an iPad.
When I called the publicist on the “groundbreaking” claim, I got this back. “Of the physicians I’ve spoken to, the user-friendly interface of the iPad app really makes patient onboarding easy and they love the ‘novelty factor’ of using the iPad as well. It’s less intimidating for patients who have limited experience with healthcare IT.”
Fair enough. But that doesn’t make OnPatient “groundbreaking.” The iPad is groundbreaking. OnPatient is interesting, useful and frankly, long-overdue competition to Instant Medical History. I hope it catches on. But it’s not much of a breakthrough.
I can’t wait to see the breathless coverage from the other tech press who don’t know the, ahem, history (sorry, couldn’t resist). If you want the unvarnished, occasionally acidic truth, come here.
For that matter, here’s the company’s own message, via video:
It’s rather low-key, actually. I have just one question: Why do they say “tax breaks” for meaningful use? The money is in the form of Medicare/Medicaid bonus payments. As EMR and HIPAA readers know, those payments are considered taxable income. Just sayin’.
The one fundamental to every EMR is some sort of computer. Yes, I’m using this in the broadest since possible since there are many EMR today that are now even compatible with something like the iPhone. However, even the little iPhone is essentially a mini computer. However, computer makers have long believed that the tablet computers were great for healthcare.
As I look back over my 4 years writing this blog, it’s really interesting to see the evolution of the tablet technology. We first bought our tablet computers over 4 years ago as we implemented our EMR. Correction, we bought our first convertible tablet computers over 4 years ago. They served us quite well. The crazy thing is that almost none of our providers used any of the tablet functionality. I can count on my hands the number of times it was really beneficial to have the tablet functionality.
Since we actually ordered the convertible tablets (converts from a laptop to a tablet), all of our users pretty much just used it like a regular laptop. These convertible tablets came up for replacement as they went out of warranty and it was pretty much a no brainer decision to just purchase laptops instead of convertible tablets.
I’m not saying that the tablets aren’t without their merits. However, none of my users really adopted much of the functionality. In fact, I think I used it more than all of the clinicians combined. Although, there was one feature of the convertible tablets that was used quite often. The swivel screen. Yes, the least technical part of the convertible tablet technology is what they found so useful. They loved being able to swivel the screen to show another provider something in the EMR.
As I researched the various tablets available today as opposed to 4 years ago, I found that no computer manufacturer offered any convertible tablet larger than the 12″ screen. The ones we purchased for use with our EMR were 14″ and we didn’t want to go down. In fact, since we did away with the tablets and just went with laptops, we moved up to the 15″ monitors and all of the providers love the extra space to more easily navigate the EMR.
Of course, the computer manufacturers say that the reason they only do a 12″ size is because no one wants to carry the 14″ ones around. It’s true that 14″ is quite a lot for many providers to carry around. That’s why we just put computers in each exam room. No more carrying computers around and a nice size monitor for your EMR wherever you go.
This said, in one of my EMR consulting gigs I’ve done here locally, the doctor carries his 14″ laptop around no problem. He replaced his laptop recently and decided to continue with the same.
I was lucky enough to just get one of the second generation Dell convertible tablets. It has not only touch screen technology, but multi touch technology. It’s a lot of fun to demo and show off. However, I just don’t see much practical application for it. At least not until I implement an EMR that has touchscreen in mind when they develop the EMR.
What are your thoughts on Tablets, Convertibles and Laptops? Have you found a compelling reason to use the tablet technology in your office?