The perfect EMR may not be an EMR

"A lot of times, people don’t know what they want until you show it to them.” — Steve JobsA few years ago I asked a patient with a laceration about her tetanus status. She was surprised it wasn’t already in our electronic medical record (EMR). “We can only access records from our own office,” I told her. “Really? You can’t see all my medical records?” she asked looking dumbfounded and a little annoyed.Over the past 15 years technology has made our world highly integrated. Google, FedEx, Expedia, Amazon and Netflix, for example, all revolutionized their respective industries. But EMRs, they’ve hardly changed at all.Data islandsPhysicians commonly complain about their EMRs being antiquated-looking, unintuitive, limited in their functionality, cumbersome, and still too reliant on paper. These problems are due to the fact that EMRs are data islands.The great advantage of digital information is that it is efficiently exchanged and searchable. Other than importing lab data, information in EMRs is typically sent and received by fax and manually filed in PDF format, which isn’t searchable, and means we can’t automate tracking and notification. Fax a referral, give patients a paper diagnostic imaging requisition or prescription, and if you want to track the progress, you have to do it manually. This increases the risk of things being lost or forgotten, which can lead to errors and unsafe patient care.When collective data needs to be viewable, one solution is registries. These often require manual re-entry of digital EMR data into a second password-protected system. In Ontario the immunization registry failed (not surprisingly) because of resistance to unpaid double data entry. The patient databases that have been built in Alberta (Netcare) and France (Dossier Médical Partagé) are steps in building bridges but exist in the same overall disconnected health record infrastructure.Dissatisfied with our EMRs, we willingly tolerate complicated, time-consuming migrations from one expensive electronic island to another (in my practice we’ve changed EMRs three times). We are left disappointed more often than not.Welcome to the Health OmniverseWhat if we built a single cloud-based online database that all users—physicians, allied health professionals, facilities, administrators and patients—could access and contribute to? What if this database extended beyond the current definition of an EHR and (in addition to patient health records) contained user demographic data (such as a physician’s name, specialty, clinical interests, address, etc.), organizational data (from hospitals and pharmacies), drug and other health science info? What if the entire database was relational and searchable, like Google?For the purposes of this thought experiment, let’s call this system the “Health Omniverse”—a reference to the theoretical Omniverse which includes all things in existence. It’s big. Likewise, this model would include all healthcare data. Here are some examples of how it would work.E-referralsWith current EMRs we must manually maintain up-to-date lists of specialists. We fax referral letters with relevant attachments, sometimes waiting weeks to discover that the referral is declined or the waiting list too long. We generally don’t have audit systems to ensure appointments are booked and rely on patients to call us if they haven’t received a notification. Patients easily fall through the cracks. The referral process is so cumbersome businesses such as ConsultLoop, in Toronto, sprouted up to help doctors. OntarioMD is in the process of setting up e-referrals as an add-on to EMRs.The Omniverse would handle the referral workflow elegantly. Picture yourself with a patient. A knee MRI confirms a large meniscal tear. Looking at the computer together, you pull up the referral module and a box pops up overlaying a map (the Omniverse would have Google Maps integrated). You select , , and a bunch of pins pop up on the map of physicians meeting these criteria. Then you refine the search with availability (the Omniverse would be able to access physicians’ calendars) and the number of pins decreases. You book an appointment or message the specialist’s admin assistant if they have disabled the self-book function. If an appointment isn’t confirmed, an automatic workflow contacts the next specialist who meets the wait-time and geography criteria. You and your patient are notified electronically of appointment confirmation and notation is made in the patient’s record. It’s like Expedia for referrals. This solution would require no new infrastructure to enlist physicians.Lab, diagnostic imagingA significant minority of tests ordered don’t make their way back to the chart. The most common reason is that patients don’t go for the test. How many doctors call patients to check and remind them? How many times do you call? Some of us create tickler systems for patients we’re worried about but few have air-tight test audit systems. I fear most use the “hope and pray” method.The Omniverse would use automated e-communication workflows to ensure that testing gets done and things don’t fall through the cracks. When a test is ordered, it is logged online, no paper requisition. The patient gets a notification by secure message. The Omniverse gives both patients and healthcare providers access to all labs (address, appointment booking calendar, testing info). If a test is not completed within a set time, patients get automatic reminders and are asked to select either or . Before they are allowed to cancel, they click on a disclaimer indicating that they understand they are declining against the agreed-upon plan. Communications are logged and physicians may select to receive notification of cancelled tests, allowing them to re-engage patients. Regulatory policies met (and exceeded) while you sleep.Consider an alternative worst-case scenario. You’re with a patient who asks, “Everything normal with my mammogram last year, doc?” You look at the chart, can’t find the report and call the imaging centre. They say they faxed it last year, the result highly suspicious for breast cancer. You freeze in a cold sweat, fearing a legitimate complaint to your regulatory body.In the Omniverse, every step in the process is tracked electronically and the status marked , ,. It’d be easy to view the progress of an individual test and rely on automatic notifications of tests delayed in progress. No need to call the lab. It’s like FedEx for lab testing.EMR 2.0In the Omniverse EMRs wouldn’t exist as we currently understand them. Apps would connect users to the database and function as operating systems to display and work with data. The physician/ healthcare workers’ app would be their “EMR app.” The patients’ connection would be their “PHR (Personal Health Record) app.” But unlike the EMRs of today, the apps would not store any data.EMR apps could be customized to specific work environments. In theory, healthcare workers in one office could use different EMR apps since they would be working with the same centralized data. If a physician didn’t like an EMR app, switching would be as easy as turning one off and another one on, just like switching web browsers.Developers could create a wide variety of inexpensive EMR apps because they would be simpler than current EMRs. Developers would be highly competitive, building modern, high-quality, and evolving apps since their products could be discontinued by users as easily as modern apps are discarded today, a marked departure from the process of migrating an EMR today.PrescribingA patient told me the other day she took a prescription to the pharmacy but the medication wasn’t in stock. She went to another pharmacy, dropped off the prescription, waited the obligatory half-hour, and ultimately wasted over an hour of her time.In the Omniverse there would be no paper or emailed prescriptions. All prescriptions are logged into the database. The patient chooses which pharmacy to direct it to using the PHR app, usually set up in advance as an automatic workflow. The pharmacy gets a notification and automatically messages the patient to choose or . If a drug is not in stock, the physician is notified with a pop up before completing the prescription. The Omniverse would have access to a real-time territory-based drug inventory.The PHR app notifies the patient when the pharmacy logs the prescription . Once dispensed, the prescription will be labelled in the database ensuring the physician, pharmacist and patient are on the same page.If the pharmacist has a question about the prescriptions they could send an e-communication to the physician, which would pop up as an instant message on their EMR app. For example, a limited use code just a quick click away, press send and done. No fax or phone call needed.The Omniverse would also identify patients at risk of opioid abuse. Physicians would have access to patients’ complete prescription history. It would take only a few moments to determine if someone requesting narcotics received them elsewhere (when, from whom, and how much). No separate narcotics registry required.Canada Health Infoway is debuting a national e-prescribing project, PrescribeIT. Prescriptions are sent by secure message to one patient-selected pharmacy, unlike the Omniverse (and countries you might not expect such as Albania), which log prescriptions online letting patients fill anywhere. PrescribeIT claims to “integrate seamlessly into EMRs and pharmacy management systems” but there remain situations where paper prescriptions must be used. Pharmacists can e-communicate with doctors but patients are left out of the loop—and PrescribeIT is arguably the pinnacle of e-health in Canada.ChallengesAs with any system changes there would be challenges, for example, stakeholder adoption, data stewardship, privacy, security and, of course, Metcalfe’s law, which dictates that the usefulness of any network corresponds with the number of users it has. Physicians are accustomed to switching EMRs but pharmacists, hospitals, and other institutions are a greater challenge. We would need to give those stakeholders compelling reasons to join.With all information available all the time, users could get inundated with data. Automatic workflows will need to be developed to get the right data to the right users at the right time. We’d have to develop common data standards such that the info could easily be used by all.Privacy would be protected by allowing only users in a patient’s circle of care to view their medical records. Patients could control privacy through the PHR app, allowing new users to access records when necessary, such as when seeing a specialist or in the emergency room.With centralized data there would be more significant risk of cyberattack. In 2007 it happened in Estonia, which has perhaps the world’s most connected e-health network. This shut the system down for a few days but afterwards they created redundant data repositories in multiple countries for backup and established a national department for cybersecurity. These are experiences we could learn from.The best of both worldsIn his January 2019 article in the CMAJ, Dr. Nav Persaud, a family physician and scientist at Li Ka Shing Knowledge Institute, argued that after many years of attempting to solve the interoperability problem, the result has failed to live up to its promise. He suggested that in order to properly connect and share records “we should select a single system and make it the national primary care electronic medical record”—a view echoed by Dr. Brian Goldman, host of the radio program White Coat, Black Art. Senior leadership at OntarioMD disagreed, arguing in the CMAJ that one system would create a monopoly, reducing competition and our collective influence over the EMR industry. They wrote that physicians need customized solutions to meet specific needs.The current EMR paradigm moves toward interoperability at a snail’s pace, doing complicated digital contortions to send data where it’s needed, often failing. The Omniverse would be interoperable by design. Access to it, like the internet, would be open to all at anytime using interchangeable apps.In other words, if we were to marshal the collective will to build this kind of system, we wouldn’t have to choose between Dr. Persaud’s vision and OntarioMD’s. We could have it all.Dr. Jonathan Marcus is a family doctor in Toronto. His writing on practice management and healthcare technology has appeared in the Medical Post, and he has spoken at the Ontario Medical Association and the CFPC’s Family Medicine Forum on electronic communications in healthcare. You can reach him at jonathan_marcus@mac.com.You can read more about the “Health Omniverse” in an upcoming series of blogs at CanadianHealthcareNetwork.ca.

The perfect EMR may not be an EMR

Register for free access or login.

More Blog Posts in This Series

Axe the silos and the fax will axe itself

COVID tracking needs a better digital health system

The iPhone figured it out, why can’t my EMR?

Blog Author

Jonathan Marcus

Related Topics