Computerization in the world of medicine is fraught with so many difficulties that are unique. In the business world, all people involved understand that increased performance should translate into increased income. As such, computerization, if properly implemented, should be our friend and not foe. In medicine, there is often a clash between business oriented HMOs and the physician who directly deals with patients. For a physician, improved performance may mean more testing, more treatment and more time. And it may very well be that the rewards of such efforts (both health-related and financial) only manifest many years, if not decades, later. HMOs on the other hand, like any business, must pay salaries today. If their costs go up, they could literally fail. As such, the same computerization that may facilitate the business side of medicine may slow the clinical work. Doctors resent being “data entry people” even though this is the only way for fiscal managers to track indices of performance.

What is needed is a system that eases the doctors’ tasks and workflows while still providing all of the data that the “bean counters” need. If such a system were to exist, then doctors would embrace it. If such a system allowed doctors to intuitively interact with medical records via interfaces that did not literally block their view of the patient (as does a computer monitor on most doctors’ desks), we would see adoption rates of Electronic Medical Record (EMR) systems dramatically rise.

I would suggest that EMRs of the (near) future should have the following features:

1) EMRs need to be entirely web based. Gone are the days when individual computers would need to be maintained with collections of hardware and software to support. And of course, the larger the system (like the whole UK ), the harder to maintain remote systems. The web is the ONLY way to make updates quickly and widely.

2) Interfaces need to be visually comfortable and fast. There are enough technologies out there for making web based interfaces to respond quickly. Adobe’s Air and Microsoft’s Silverlight systems definitely have the potential to deliver effective, responsive tools via the web. Silverlight was used to bring the video of the 2008 Summer Olympics to millions of viewers. Such a technology could be applied to x-rays and angiograms and all types of scanned documents, all contained within a country-based centralized EMR.

3) EMRs, especially those that are being developed from scratch, should start small and grow. Many doctors are still working with paper charts. That’s OK. Allow them to continue doing so BUT start forcing some elements of the chart to be entered into the EMR. AND for each element that is entered into the computer, make sure that the doctors appreciate the benefit. Example: if you make the doctors enter diagnoses, then there is the benefit of being able to check medications for incompatibility with previous diagnoses. Example 2: digital prescriptions that are automatically transferred to the pharmacy and reduce phone calls about illegibility and facilitate ordering refills. Again, as long as the interface is (a) intuitive, (b) fast and (c) saves time by simplifying certain tasks, the doctors will use it.

Over time, the doctors will become used to using the computer for more and more things like recording full history and physical exams. One BIG problem is that lots of doctors don’t type. In effect, this slows them down when they have to type in a history. If there is something else that slows doctors down even more, it is screen after screen of coded medical terms that they must choose from to complete a chart. After a while, the doctor’s eyes hurt from constantly flipping around the screen to find the little check box that says “cough.” The answer is in a fundamental redesign of the interface. I am not talking about moving a check box from one place to another OR changing the order of the screens, but more so, an adaptive, highly graphical interface that constantly reshapes itself as the doctor moves along in the chart.

Example: when the doctor needs to write a prescription, the entire interface should melt away and leave only those elements on the screen that help write a prescription. When the doctor needs to navigate back to where he was, he uses the classic “BACK” button of any Web-based interface to return from where he came. The same principle applies to entering information about any and all elements of the chart. The interface needs to constantly reform itself to present the doctor with only those options he needs to complete the immediate task. Too many options on the screen distract the doctors. So, the idea is that at any point during the doctors’ work, they need to have as FEW choices as possible presented to them.

4) Great handwriting recognition is still far off BUT limited recognition has tremendous potential. In this day and age, we have MANY templates for standard problems (follow up for wound management, blood pressure check, diabetes check and so on). So, imagine having a digital “blank piece of paper” in front of you and then having the ability to select templates that highlight the key elements of the history and physical. 

Now imagine being the doctor working with such an interface. How long would it take you to fill in such a form? Not long.

What if the patient suddenly says “oh, and doc, I am coughing a lot lately.” No problem. There would be a drop down list of additional templates for common problems at the side of the digital page. The doctor would select one of these templates and the new set of questions (with digital fields) would appear below any previously entered information. More so, if the list of patient problems is limited to the 200 or so most common complaints, then the doctor could hand write the name of the complaint and the built in OCR would be able to decipher the doctor’s handwriting and then insert the matching template. Of course, ordering tests and booking appointments for other doctors should work through the same kind of “limited free text” options. So if you want a follow up appointment for a urologist, you write urologist in the free text area and then options for appointments with the urologist would appear.

You could absolutely include voice recognition as well, giving it as an option for every place where free hand entry (or even drop downs) are available.

5) Get rid of the screen that blocks the view of the patient and replace it with a smart table (a la Microsoft surface). These technologies are expensive NOW but will quickly and drastically drop in cost. By virtue of the screens lying flat (just like paper), the doctors will feel as comfortable with them as they do with paper charts.

So, when all is said and done, I fundamentally believe that we can design large scale EMRs that will really make the difference. BUT many elements of these EMRs will need to be a paradigm shift.

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