Whitehouse: The President's Address to the Nation: 1/24/04

"And Fifth, we can control health care costs and improve care by moving American medicine into the information age. My Budget for the coming year proposes doubling to $100 million the money we spend on projects that use promising health information technology. This would encourage the replacement of handwritten charts and scattered medical files with a unified system of computerized records. By taking this action, we would improve care, and help prevent dangerous medical errors, saving both lives and money."

Prelude:

I would venture to say, that there is nothing that a physician presently does with pen and paper, that could not be done more expediently on a Tabletpc. You can make template documents to be used on all your patients, like you do now with your exam and intake forms. You can write Rx scripts from Journal, and print to a networked or IR printer.
A doctor could use a scanner to input existing documents into the Tabletpc, that are presently used as paper. In other words, scan in the paperwork that you already use and now use the same paper work on your TabletPC. Alternatively, if documents are in Word format, you can use them on a Tabletpc or port them into Journal which would allow the user to write on top of the document like with a pen and paper.  If you can find a quiet environment, you can dictate into your TPC. You can be wirelessly online with Wifi, and bookmark educational material for your patients that can be printed out at the point of care. You have the potential to network with other computers and send and receive information over the LAN or via email, if no LAN. (Labs could be emailed). With prudent backups, you will be shuffling pages with a stylus in nanoseconds instead of paper shuffling in a messy file. You can chart at the point of care and be finished at the point of care. 

Introduction:

What is EMR? EMR (electronic medical records) refers to a category of software products designed for the healthcare industry. There was a time when every patient encounter, every chart, every prescription, every bill, every aspect of managing a practice, was accomplished manually. The choice isn't whether to convert your practice to EMR, it's simply when. And which EMR to buy...

Ideally, your practice will be best served by a robust EMR program. The main goals of any EMR system should be to enhance production and facilitate the quality of care. The two most important features are simplicity of using the program and input speed, at the point of care. Beyond that, the program should be shared with doctor and staff and no one should be intimidated by the complexities of the system. In addition, the solution should offer flexibility and custom features, so that everyone feels comfortable not only with the technical aspects of the program, but also the way in which documents are created. The doctor should be able to customize the program to reflect the way they practice and not have the software program dictate practice protocol. Doctors have learned to take care of patients in a certain way, and the software and computer has to fit into the work flow, not be perceived as extra work, and not interfere with the doctor-patient interaction. Another mandated feature is physical portability, resulting in, at the point of care documentation. This equates to avoiding subsequent time, often after office hours, reviewing and updating records on your PC or chart.  Ultimately, the software and hardware, must be able to facilitate communication and save time—that’s the key.

Historically, the chart has been a repository of paper. An EMR system is a patient information network as well as an office management tool. Used as the primary source for patient records, it is a modern medical chart with the same structure, scope and information as a paper-based record. The chart is filled with details about the patient and their care. The power of an EMR Chart is in the data it holds, but even more important, is the ability to retrieve data back out or extract it visibly and or print it out for a third party. There can be volumes of information in a given chart, but the doctor may only want to see one specific part. A good EMR has the equivalent of flip switches or filters, which allow the viewer to see only what is applicable and or desired.  All information needs to be available, but not in your face all the time. The quick access to and retrieval of information are what doctors consider most impressive. Retrieving and viewing data by date or visit are simple and straightforward when the user interfaces are properly designed. It enables immediate access to information.

Desktop machines lack portability. Palm and PocketPC platforms are fine for reference material, but too small and underpowered for EMR. For me, a TabletPC is better than a Desktop PC, a PocketPC (PPC), or any Handheld PC, at least for EMR, simply because it is a mobile, yet robust communicating tool, with the caveat that it does not fit in your pocket. As a long time PDA user, that is a genuine compromise for me. For better or worse, it is all about compromise.

The TabletPC demonstrates critical "visual real-estate," and is readily network able with other LAN PCs. Real time voice dictation is built in to the OS as well as handwriting recognition in various forms from Journal to Write Anywhere to Tablet Input Panel. Whatever you can do with a pen and paper or a desktop PC, you can do with a Tabletpc! Forget navigating horizontally, vertically and diagonally with a mouse; move  directly and intuitively to the target with a stylus/pen! Additionally, when networked, other staff can input data besides yourself, in "real time," enabling a Triage Approach to patient care. For example, a historian can prepare the history and ROS, the front desk the demographics, a nurse the vitals, all prior to the doctor examining the patient. Then, the doctor digitizes the exam findings and chart note. (IMO, this is best started with a protocol template that is easily customizable, rapidly inserted and easy to change with hyperlinks to exam findings/tests and appropriate drop down list boxes, etc.

I am partial to an EMR that has the option to uses color coded, sophisticated XML hyperlinks to make customized, editable, changes. What this amounts to is the doctor reads the typed soap note and the clicks on only the portions that need change. This means a user can rapidly make changes by clicking on hyperlinked text e.g.. A male patient of 50, presents with neck pain that is moderate and constant....... In this simple scenario when you click on the underlined text, a list box pops up with custom answers that are changeable and reflected in the soap note. The notes reflect a "What you see is what you get" philosophy (WYSIWYG). All of the exam charting is done from one screen. There is no need to switch between screen to enter each section of information. The note is laid out as you write it. All information is readily viewable, obviating the need to scroll, pan and or change screens as on a Personal Digital Assistant (PDA). Of paramount importance, the entire chart note (SOAP) is visible for review, on a single screen, an important factor in a harried and hurried setting.

For patient education, the larger viewing area is obviously better than a PDA's 3.5" screen, and when wirelessly connected to the internet with DSL, you have a very potent mobile educational tool, where screen shots and patient hand outs are easily printed from the point of care, to a network printer. Point of care communication with the entire networked staff is easily accomplished with "robust office applications," not feasible on a PDA.

With respect to an EMR, I think the PDA will forever be relegated to a good "reference tool," and at best, be an adjunct device to a good EMR package that is, " hardware independent." In other words, depending on your specialty and needs, a user could use a PDA in conjunction with a Desktop or Tabletpc application, but using a PDA alone, as an EMR, is arguably not viable.

Summary Conclusion: Paper versus Digital

With the proper EMR, the entire chart is "in your face," and all aspects of patient care are each a single click away. With a sophisticated EMR, the entire soap note is on a single page, immediately presented to the viewer. It doesn't get much faster and easier and it is certainly quicker than paging thru and reading an inch thick unorganized paper chart. Any and all data can populate a custom document for paper communication when needed.

Remember, to network share the EMR so others can input data. Sure typing is preferred for some aspects of charting, but you don't have to do it!

Databases: All EMRs need to centralize on a database where data can be shared with providers and hospitals. Medicine must create value with improved efficiency through electronic medical records. This will improve evidenced based standards and only serve to advance health care.