7 Essential Habits of highly effective EMRs — Part 1

Note: I am using EMRs here as a generic catch-all for all healthcare IT that doctors, nurses, patients hospitals use.

Today a drug discovery scientist in the US performs millions for experiments daily to find a new target molecule for treating a disease. The work involved of setting up and analyzing the results of the experiments was one of the most labor-intensive part of the job about 20 years ago. Since then technology has been brought in to automate the set up of these scientific experiments, and visualization and AI tools have shortened the time required to analyze the output data, thus making these scientists some of the most productive in the world. A similar story plays out on the commercial side of of a drug company, where a mix of technologies have been used to get their products to the neediest patients. The second example is pertinent as it operates in a more complex interdependent environment than the first. To get a drug to a patient requires one to get the insurance firms, trade channels, the doctors, nurses, pharmacists and patient’s families to get aligned before the patient can take the first dose. But it has be done. Some start ups in the US are now able to predict potential patient candidates for a new drug for rare diseases by interlinking EMR, claims and social media data even before the patient has been diagnosed! Scary but perfectly legal.

So why are doctors and nurses in hospital, also a multi-player, inter-dependent environment, such reluctant users of EMR technology? For someone, who spent time expounding the use of technology in the pharma world I was shocked at the level of angst and heartburn that EMRs give to doctors and nurses. However, the very same people use other technologies heavily, including sophisticated machines, so why aren’t they clamoring for an EMR?

Dr. K is a senior surgeon at a community hospital which is using our EMR product. He is scrupulous and extremely effective in his chosen field. He has a kind but brusque attitude towards his patients. Nevertheless, his patients love him, and come from far off nooks of the country to see him. Dr. K maintains a record of all his patient notes going back over 20 years. In addition, he has a habit of maintaining a personal register of all his past surgeries. Why? Because, he likes to keep track of his surgical run-rate i.e the number of surgeries he performed in a given year. I assumed that this fascination with the run-rate is a spillover effect of him being a cricket buff, but it does show a desire to keep track of his patients. In any case, he uses his iPhone to chat with his grandkids in the US, and WhatsApp to trade barbs with his colleagues here. However, he refuses to remember the password to log into our system. All the need for upper case, lower case, special characters requirements for a password really fluster him. In other words, even getting into the EMR is too complex for his simple need of jotting down a few notes about the patient. Further, there was no way our system could support him in planning for his surgery, where he might simply sketch on a paper before the surgery and writes down notes next to it on his plan. Only on seeing our mobile app which allows doctors to attach a photo directly into the patient record, did we see any sort of excitement about the EMR.

Strangely, for a country that is bursting at its seams with population, infertility clinics are one of the fastest growing segments within the healthcare business. And Dr. J is one outstanding IVF specialist, running a bustling practice with a very high success rate. She is methodical, and every step of treatment is precisely tailored to a calendar. For every cycle of a patient, the care team at the hospital follows a strict protocol for drug regimens, lab investigations, scans, in-vitro procedures and follow-up visits . In fact, the entire EMR for Dr. J looks like a calendar, where she changes the plan and updates her notes on the calendar. Pulling in data together is the main value of an EMR for her, and she is an ardent user. However, recording details for every discarded oocyte frustrates her, as her primary concern is the success rate of the procedure rather than documenting. Given the high loads, another operational concern is to ensure all procedures and tests have been billed properly.

At the other end is Dr. S, an experienced family physician who patients completely fill up the hospital. Most patients of his are poor, and Dr. S even foregoes his modest consult fee for anyone who asks. Unlike most other doctors these days, he spends as much time as required to hear out his patients. In this sense, he is the quintessential family medicine practitioner that I thought only existed in novels. He uses his prodigious memory of one’s family and their related history to inquire about them, such as, is your father’s sugar in control, or has your cousin’s foot ulcers healed? He writes copious notes for all his patients, but doesn’t use much other technology. Upon being told to use the EMR, he dutifully filled out a quick note onto the computer like “Pt c/o tiredness, loss of appetite, wt. h/o DM, poor control, refer to Dr. H”, but only at the end of the day after seeing all his patients. I feel guilty and embarrassed every time I see him work late at his age on account of our software. Unfortunately, the only thing he cared about, whether his patients are doing well or not, was something that we could not do with our product. In addition, being able to waive off his fee for a patient was not something that was easy for him to accomplish either.

At this point, I should point out that our product, HealthScore, is by no means a lousy product. If anything, ours is one of the better platforms in terms of usability based on the feedback we have received from doctors. In fact, doctors who have returned from abroad are ardent fans of our product for the sheer simplicity and usability of our product. However, given that doctors abroad vehemently hate their EMRs, thats not saying much. Yes, bogeymen for non-adoption by doctors are aplenty ranging from lack of standardization in care within and across specialty, money-minded doctors that look at EMRs as a cost that cannot be billed, and the cruelest one of them all, that doctors are too stubborn to change. All these have some merit, but even if we focus on the sizable segment of doctors in our country that do practice good medicine with integrity, we are left with the inevitable conclusion that EMRs, as we know it, must be ineffective.

And yet we continue to define our conversations about EMR with the same language that those in the US and developed worlds use where it has failed. We endlessly debate interoperability, CDSS, CPOE, PACS, data ownership, HL7, SNOMED, patient privacy, encryption at rest etc., which at best only perpetuate the failed systems, and at worst, are utterly meaningless to most practicing doctors. Granted these ideas are important, but these are nothing but high quality pipes and wires inside of a poorly constructed building that no doctor wants to buy.

The rest of the series discuss elements that are essential for practicing clinicians.