What is Wrong with EMR?

1
What is Wrong with EMR?

• James J. Cimino , M.D., Columbia University
• Jonathan M. Teich , M.D., Ph.D., Partners
  Healthcare System
• Vimla L. Patel , Ph.D., DSc. McGill University
• Jiajie Zhang , (Organizer), Ph.D., UT Houston

2
What is an ideal EMR?
3
This Is The Ideal EMR!

• Complete
• Accurate
• Timely

4
Status of Current EMR
many non-trivial problems
5
Four Perspectives

• System functions (Cimino)
• Clinical (Teich)
• Cognitive (Patel)
• Human-Computer Interaction (Zhang)

6
System Functions PerspectiveJames Cimino

• Two Models of EMRs
• Old Vision
• New Vision

7
Two Models of the EMR

• Financial system add-on
• Repository

8
Financial System Add-On
Patient
9
Repository
Patient
10
Old Vision

• Medical record as history
• Terminology as codes

11
Problems with the Old Vision

• Cognitive overload
• Poor coordination of caregivers
• Computer unable to help with plan

12
New Vision

• Medical record as Daytimer
• Terminology as knowledge base

13
Medical Record as Daytimer

• Future is more important than past
• Goals are stated
• Alternatives are anticipated
• Status can be determined
• Computer can help with planning and timing

14
Terminology as Knowledge Base

• Coded data become symbols
• Care plans can be codified
• Computer can share tasks in the care process

15
Promises of the New Vision

• Initial status is determined
• Problems and tasks codified
• Daily notes are updates to status
• Progress can be charted
• Milestones can be anticipated
• Patients distance from desired state can be
  determined
• Expert systems can help with state transitions

16
Workflow, scenarios of care, and the EMR

• Jonathan Teich, MD, PhD
• November 9, 1999

17
A little disclaimer
18
(No Transcript)
19
What are the Winners?

• Results review
• No work required
• E-mail
• Immediate benefit
• Important or requested alerts
• No work, high importance
• Non-judgmental, valuable immediate benefit
• Order sets

20
What are the Losers?

• Supplying reasons for orders
• Multiple click sequences
• Prednisone tapers without support

21
 EMRs run into acceptance problems because

• Theyre not oriented to the scenario
• Immediate effort gt Immediate benefit
• Theyre slow
• Perfect is the enemy of good
• They over-use technology
• They have an activation energy
• They follow data categories, not clinical
  scenarios

22
Scenarios ambulatory

• Coming into the office
• New patient precis
• Familiar patient review
• End-of-visit
• Phone call

23
Scenarios inpatient

• Rounds
• Results review
• Orders
• Entry and processing
• Prioritize tasks among several patients ED
  display
• Daily notes
• Signing out

24
Scenarios community/patient

• Ask a question
• Request a service
• Convey information
• Do it all without phone tag

25
The bang per buck approach

• Computerize if
• Immediate Workflow benefit cost benefit
  (future usefulness x lifetime) gt Extra work
  Extra time
• WI CS (FU X L) gt WE TE
• Example inpatient notes
• Example ambulatory documentation
• Add no-input benefits

26
Property Workflow

• The one-click rule
• Common things quickly, uncommon things possible
• Associated information

27
Property Data re-use

• Med list -gt prescription -gt refill
• Meds, allergies -gt conflict checking
• Problem list, dx -gt pathway, flu shot reminder
• Structured docu -gt later default aging

28
Other issues

• Shortcuts, templates, and pre-fills
• Parsimoniousness problem list
• Simple
• Usable
• Avoiding aggravation
• Appropiate alerting modes
• Avoiding over-alerting
• Inclusive approach data capabilities

29
Ambulatory documentation

• Modes
• Dictation
• Hand-entry
• Structured entry
• Structured dictation
• Voice recognition
• Partial structure
• Cost it out

30
Post-high-tech people, paper, and free text

• Sign-out sheets
• Structured documentation
• Mix structured and free entry

31
Make something better and nothing worse
32
Studies of the providers day

• Tang time spent in activities
• Awoniyi
• Lee what is liked vs. what is used
• What problems can be helped by information tools?

33
Whats Wrong With The EMRA Cognitive Perspective
Vimla L. Patel, PhD, DSc, FRSC Cognitive
Studies in Medicine Centre for Medical
Education McGill University Montreal, Canada
34
EMR and Paper-Based Records

• Cognitive artifacts
• Embody processes
• Promote use of heuristics
• But, as I will show
• They support different cognitive processes
• Paper Focus is on exploration and discovery
• EMR Focus is on problem solving

35
Information in EMR and Hand-Written Records
36
Information Management and EMR Use
of Record Contents
37
First section from paper-based record (Pre-CPR)

• 74 year old woman, whose diagnosis was made in
  February, as she complained of polyuria/nocturia
  and fatigue for a few years. She was told her
  sugar was very high and she was sent to Dr. K.,
  who started her on Diabeta 5 mg/d and sent her to
  Dr. S. in ophthalmology who reported normal
  retina. She lost weight, her polyuria improved,
  her bladder urgency got better, and her glucose
  values improved dramatically. She does no
  monitoring at home. She had to be hospitalized
  for an ankle fracture after falling on ice, for 3
  months. At follow-up, Dr. K. seemed pleased with
  the results.

38
First Section from Electronic Medical Record (EMR)

• CHIEF COMPLAINT Type II diabetes mellitus
• PERSONAL HISTORY
• SURGICAL cholecystectomy Age 60 years old
• MEDICAL hypothyroidism asymptomatic since 25
  years
• LIFE STYLE
• MEDICATION
• DIABETA (Tab 2.5 MG)
• Sig 1 tab(s) Oral before breakfast
• SYNTHROID (Tab 0.125 MG)
• Sig 1 tab(s) Oral before breakfast
• HABITS smoking 0 alcohol 0

39
First Section from Paper-Based Record (Post-EMR)
Diabetes type I X age 4 Currently on N54 -
N28 R6 - R2 Measure with OT II Glucose
levels lt130 130-180 gt180
AM IIIIIII IIIIIIIIIIIIIII Lunch
Supper IIIIIIIIII
Bedtime IIIIIIIII IIIIIIIIIIII Last HbA1C since
April 96 7.4/7.2/6.7/6.6/8.9 - higher values in
log book Retinopathy NIL March
97 Nephropathy NIL Oct. 96

40
Sections of EMR Accessed by Intermediate and
Expert Users for Two Typical Cases
Category of Information (in order on CPR screen)
Categories Accessed by Intermediate
Categories Accessed by Expert
1. Chief Complaint 1 1
2. Past Medical History 2 3
3. Life Style 3 6
4. Psychosocial Profile 6 3
5. Family History 7 6
6. History of Present Illness 8 8
7. Review of Systems 9 3
8. Physical Examination 10 4
9. Diagnosis 11 8
10. Investigations 9
11. Treatment
11 9 2 11
41
Semantic Representation of Natural Language
Analysis
THOUGHTS AND IDEAS
42
Types of Propositions

• Single propositions
• A single idea
• She lost weight
• Embedded propositions
• Contain one or more single propositions
• She lost weight relative to her premorbid
  baseline
• Linking propositions
• Connect different portions of the text
• She lost weight and control of her blood sugar
  improved

43
Propositional Analysis Pre-EMR
74 year old woman who was diagnosed in February,
as she complained of polyuria/nocturia and
fatigue for a few years. She was told her sugar
was very high...
44
Propositional Analysis EMR
Chief complaint Referred by Dr. D. Type II
diabetes mellitusPersonal history Surgical
cholecystectomy Age 60 years oldRemoval of
kidney stone on left side
45
Propositional Analysis Post-EMR
Diabetes type I. Currently in N54-N28. Measure
with OT IIGlucose levels lt130/130-180/gt180
46
Proposition Type by Medical Record
47
Changes in Reasoning Patterns

• Paper Records
• Data-driven reasoning
• Electronic Medical Record
• Problem-directed reasoning
• Return to Paper Record after EMR

• Problem-directed reasoning

• Residual effect of EMR on behavior (after EMR
  removed)

48
Diagnostic Reasoning
Paper Record
Electronic Medical Record
49
Paper-Based Medical Records

• Record before EMR
• Coherent discourse structure
• Fewer inferences needed
• Temporal order of causal relationships explicit
• Data-driven reasoning
• Increases cognitive load
• Linking propositions constrain interpretation
• Return to paper-based record after EMR
• Hypothesis-directed reasoning
• EMR structure maintained No linking propositions
• Less Information more inferences needed

50
Electronic Medical Record

• Supports hypothesis-directed reasoning
• Provides flexible structure for data entry and
  review
• Provides direction and reminders
• Suffers from lack of linking propositions
• Interpretation relies on the users
• Despite time-stamping of events, lacks
  representation of temporal relationships in
  evolution of disease processes
• Area for research and implementation

51
(No Transcript)
52
Human-Computer Interaction (HCI) Perspective

• Jiajie Zhang, Ph.D.
• Department of Health Informatics

53
Usability Problems of Current EMR
Low Acceptance of EMR

• Desired Features
• Easy to learn
• Easy to use
• Little or no memorization
• Low mental workload
• Error proof
• Task-Interface match
• User-Interface match
• Subjectively pleasing

• Current Status
• Difficult to learn
• Difficult to use
• Too much memorization
• High mental workload
• Error prone
• Task-Interface mismatch
• User-Interface mismatch
• Not subjectively pleasing

54
Cost vs. Benefit of Usability

• Phone 0.15 seconds/digit ? 1,000,000/year
• 757 3 pilots ? 2 pilots
• Pager 3000 words ? 150 words
• Form 100,000 total ? 536,023/year
• Sign-on 20,700 total ? 41,700 1st day
• IBM 1 investment ? 100 return

Nielsen (1993)
55
Is the Code Useful?

• 48 code is for user interface.
• Usability engineering ensures that the 48 code
  is usable.

Nielsen (1993)
56
Accidents due to Human Errors
(Van Cott, 1994)
57
Annual Death Rates in US
Philadelphia Enquirer (9/12/99)
58
Direct Interaction Interface

• Direct interaction interfaces are transparent to
  users such that
• users can directly and completely engage in the
  primary desired task.
• users do not have to interact with the interfaces
  that mediate the system.
• With direct interaction interfaces,
• users are able to easily, accurately, and timely
  retrieve, seek, gather, encode, transform,
  organize, and manipulate information to
  accomplish desired tasks.

59
Normans Action Theory
Direct Interaction
60
Bridging the Gulfs

• From the system side
• by direct interaction interfaces.
• From the user side
• by extensive and long-term learning.

X
61
Mapping between Task Interface
62
Shneidermans Object-Action Model
63
Task-Interface Mismatch
64
Formats Determine Functions










65
(No Transcript)
66
(No Transcript)
67
Conclusion

• In order for EMR to perform the functions that it
  is promised to perform and to be universally
  accepted by healthcare professionals, user
  interface design principles should be
  systematically applied to the design of EMR at
  the earliest possible stage.

68
Usability Now!