My Ideal Electronic Health Record

Give me technology which improves my life and that of my patients, or give me death.  Medical records must be informative, efficient, and flexible; like the physicians they serve.  For me, a medical record does not contain just a collection of problem lists, prescribed medications, and immunizations; it is a noteworthy account of the health care provided to another human being over a lifetime. 

Recently, I attended a baby shower of a patient who is now an adult.  (I am a pediatrician.) I brought her medical chart wrapped with a satin bow as one of her gifts.  I was her physician for many years; my father had taken care of both her and her mother as children.  Her growth, development, immunizations, and illnesses were all recorded; but so were 25 years of life experiences, trials, triumphs, and tribulations.  The back section contains drawings she had given me, newspaper articles of her achievements, graduation announcements, and her wedding invitation.  Obviously, medical records register growth parameters, vital signs, and sick visits; but they also encompass my relationship with my patients. 

New technology must be better than what I already use; otherwise there is no reason to change.  In 2009, the Department of Health and Human Services led many to believe (incorrectly) “using electronic health records will reduce administrative burdens, cut costs, reduce medical errors and most importantly, improve the quality of care.”  Few, if any, of these goals have materialized.  IT experts are tinkering with the grand design of a documentation method that has satisfactorily served physicians for hundreds, if not thousands, of years.  It is no small undertaking; a certain degree of diligence is required for conversion to experience success. 

Administrators, MBA’s, and CEO’s know nothing of providing patient care, yet they spend obscene amounts of money on fancy automated systems which are grossly incompetent at facilitating our workflow.  Electronically generated notes take up to six faxed pages instead of the requisite one, yet provide little in the way of useful information.   How is that an improvement on what we had before?  Non-physician health leaders are missing the forest for the trees as they search for innovative ways to enhance data collection while overlooking the accumulation of critical information to support proper medical decision making. 

Electronic records need to be user friendly, free or low cost for physicians, and reduce the workload, but current systems are far too cumbersome to accomplish this task.  The more complicated and structured the program; the less likely it appears to improve patient care while increasing the physician burden at the same time. Few primary care physicians have weighed in on technology needs because we are busy seeing 20-40 patients per day.   We do not need computers to do the thinking; we need them to do the documenting with speed and accuracy.  

To improve care quality, adaptability is also imperative in any electronic system.   Using a simple, basic, and more customizable interface would allow each specialty to tailor the structure to fit their individualized needs.    Clicking pre-defined boxes on a computer screen does not capture the essence of each patient nor adequately describe the distinctive features of various medical conditions.

Visually, my ideal EHR would be a “paper chart” on a computer screen.  The first page would be a standard intake form providing the general health background, birth history, past medical and surgical histories, allergies, immunizations, medication list, and pertinent family history.  The second page is the problem list and other necessary details depending on medical specialty.  The third and fourth pages would be growth charts and then the immunization record follows.  Those pages could be accessible by tabs on the left hand side of the screen to review or update when necessary.

Pressing the edge of the screen would allow review of previous notes with one touch.   There would be tabs on that right side to review labs, radiology reports, and “one-page” notes from consulting physicians with the impression and plan succinctly summarized at the top.  The last tab in the bottom right corner of the screen would contain scanned newspaper articles, pictures, notes, and cards from my patients; I call that my “friendship” section. It is a “custom” add-on that should be offered to primary care physicians like me. 

The structure for each note would be SOAP in format; it would take 60 seconds to record an office visit by dictation. A program would convert the dictation to a word processing document in the SOAP layout.   Auto-fill would be unnecessary with such a swift and efficient system.  It must be resistant to crashing and have an auxiliary back-up to store new notes if glitches arise so as not to negatively impact patient care.  Our office has been open during earthquakes, a flash flood, when the power is out, in a windstorm, and when there is snow, sleet or hail (just like the post office.)  Our paper records have never been inaccessible or unusable.  

Do not forget the fundamental purpose of medical records in the first place.  They are a chronicle of diagnoses, treatments, and follow up for myriad of medical conditions. Systems attempting to be “one size fits all” lead to over collection of redundant information in the name of comprehensiveness. Unfortunately, no single system has yet achieved the Holy Grail of being cheap, efficient, and accessible while improving the quality of patient care.  Only technology that enhances the practice of medicine for physicians should make the final cut.  

It is vital that new technology benefits both patients and physicians, enriching our non-judgmental, empathetic, and long-term relationships.   Seven years ago, I lost a college-aged patient in a car accident.  Placing the final dictation in her chart a week later gave me the opportunity to reflect on our relationship and her assorted illnesses, injuries, and well visits over almost two decades.  What a treasure to behold after years of friendship and medical care.  Her paper chart was tangible proof of a life well-lived.

I recently contacted her mother to inquire if she wanted her daughters’ medical chart.  She said it was a gift to see her daughter through the eyes of her physician, who was there every step of the way.  Medical records are more than metadata on a computer screen; they are a sacred chronicle of our enduring connection with our patients in life, and even in death.   When an EMR can do that, I will be thrilled to embark on a digital journey.  Until then, give me paper or give me death.