SmartPhones are the most convenient devices when it comes to doing things at the “Point of Action”.  In individual Physician Practices, Smart Phone interfaces may not be needed as much as they are needed in Hospitals and Emergency Rooms.

In some hospitals, they have been using desktops or laptops mounted on litle desks with wheels to be wheeled along or set in a corner. They are tethered to the Hospital backend systems with Wireless or Wired connections.  They seem clunky and inconvenient to use but never the less seem to be used.

Tablets or Laptops may be convenient also but not as convenient as a small form factor computer like an iPhone, iPodTouch, BlackBerry or Android phone! These are especially handy when used in Emergency situations like in an ambulance while taking in vitals and other readings and sending them ahead to the hospital emergency room. This can enable the hospital to be ready for the patient and speed up a lot of communication that happens only when the ambulance arrives at the hospital.

Even in the Hospital in-Patient rooms or the Operating Room, SmartPhones are easier to deal with than a laptop or a desktop even with wireless connectivity.

The problem with EHR SmartPhone interfaces is to come up with natural, easy to use interfaces. With a small form factor it is quite a task to fit a lot of what goes into an EHR interface into such a small space. Even with large LCD screens EHR interfaces take up a lot of the screen real-estate. Compressing a lot of that into a small screen like that of a smart phone is quite a task!

Quite a challenge but very useful if someone does it!

There was a line that was 200 long but they had 7 or 8 nurses doing the flu shots and the line was moving fairly quickly.

But the amazing thing that was made possible, courtesy of Electronic Health Records was what happened at the end of the line after you had your flu shots. They did a quick scan of your membership card and checked on outstanding or overdue health checks. In my case, they found that a test for Colon Cancer was not done and so they set it up with thier lab to have it done immediately!

All of this was made possible, only because my health records were electronic and they were able to see what was overdue for my preventive care with a swipe of a card. As long as I was there for the flu shot, they could as well have me do my preventive health checks also!

I cannot imagine any healthcare facility delving into Paper files for each member who shows up for a flu shot, digging out tests that were done and Preventive Healthcare tests that were overdue, especially when the line is 200 long! They did this because they could, with just a swipe of a card!

We keep talking about moving from an illness based healthcare system to one of Health and Preventive healthcare. From a practical point of view, you need to encounter situations like these to see what a leap of healthcare Quality, just making healthrecords electronic, enables!

Just Preventive Healthcare alone will save any payer – the Medicare/Medicaid ones or the Insurance Companies, in spades, money they dole out in treating patients after they get too ill! What a shame!

So when someone talks about Preventive Healthcare saving money and EHR enabling it, believe you me, they are little things like the one that make them possible!

EHR Adoption and tthe current deadlines like 2010 and 2014 are all artificial deadlines. With just a bill they can be postponed again and again, till things like Meaningful Use, Certification of EHR Software are all worked out completely!

We have seen this movie before with the Sarbanes Oxley Act and Compliance with the act that is needed. The Act was passed in 2002 and a number of extensions for compliance were issued time and again!

I have a feeling that the longer we go with a lot of uncertainties about what meaningful use is or imprecision around how EHR packages will be certified, I am afraid that deadlines will be extended again and again!

I hope that this does not happen, but given past experiences with anything the Federal Government does on a scale that it is trying to do with the Stimulus Package and EHRs, it is very likely that deadlines get extended!

This can have a lot of profound consequences on a lot of companies and people. EHR companies may not see the same kind of rampup they would experience if the deadlines are not extended. In some sense, these are not deadlines but only announced dates. Nevertheless moving them could affect a lot of companies and people!

That way Year 2000 was better. You didn’t have a choice. It came whether you were read or not!

Having gone through many hype cycles like Year 2000, Artificial Intelligence, Dot Com, etc I am a bit jaded when everyone is optimistic! That’s the time you need to break out your cynical evaluation of what’s being said. That’s the time everyone starts believing their own Kool-Aid when some level of skepticism is healthy and good.

During the Dot com boom, everybody had bought into the idea that Brick and Mortar stores were dead and every business in the world would be done online!

Did not happen that way; even though some things changed many things still remained the same. Of course, there were hundreds of businesses that changed for ever and online shopping is here to stay.

Something similar is likely to happen in the EHR adoption space also, most likely! Physician practices that were anyway postively inclined to automate their Health Records will go at full speed, Stimulus Payments or not, if they have not already! There will be many that will try it without a lot of planning and thought and fail as a result. This may be as much as these practices not being fully prepared with the right expectations of cost and time to successful implementation as the quality of people doing the implementation.

The Dot com boom attracted to technology, people who did not have any business doing technology just because of the demand for such people. The same may happen in 2010 and 2011 with great demand for people with EHR experience or NOT! This is where many things can go wrong and Physician practices may become even more jaded than now.

However, over the long run they will see success but it will be a quick upward curve in demand and adoption followed by a quick fall and then a gradual rise!

Electronic Health Records will buy all stakeholders incredible ROI but they may not see it immediately! That’s where discontentand disillusionment may set in. Hope it’s a short phase.

Clinical-decision support gains attention at AMDIS – is an interesting article summarizing this situation. It appears that current Clinical Decision Support systems come in the form of articles released as Best Practice Guidelines or Evidence-Based Medicine articles that are peer reviewed and published. These help physicians help in their Diagnosis and Treatment Plan designs at the end of each visit.

It appears that in Hospitals, they would need actual proof of physicians having used these articles or Clinical Decision Support systems in the form of statistics.

Clinical Decision Support systems, especially, if they incorporate formal studies of treatment or process efficacies, can reduce medical errors and adverse drug events to a large extent. WHO found that if a simple 20 point surgery checklist is followed in every surgery, morbidities and mortalities are reduced drastically. 

Clinical Decision Support systems when combined with EHRs properly stand a very good chance of achieving the now seemingly elusive goal of moving healthcare more towards prevention and wellness rather than illness!

I was a member of Kaiser Permanente, before EHR rollout and after EHR rollout! Forget the caregivers, I was very disturbed as a patient when my Physician kept turning away from me every two minutes to type something into the EHR on the desktop that was suspended from the ceiling! I can understand how the Physician can feel that this has changed the way they deliver medical care!

This is where small form factor devices could come in handy and could solve some of these problems but they are totally underestimated today!

Devices like the iPhone and iPod Touch are very easy and natural for physicians and nurses to use and it’s only a matter of time before these devices take over a lot of the EHR functions piece by piece!

If you are a nurse taking a patient’s vitals you just need that screen where you type in the details and record them. You don’t need the whole kit and kaboodle of the EHR user interface!

iPhones, iPodTouches and other SmartPhones may already be replacing pagers in healthcare! With processors becoming faster, these devices becoming less expensive, it’s only a matter of time that they get adopted quickly!

If these are woefully inadequate, there are always these rumors of a midsize iTablet device from Apple! 

Small form factor devices are coming! Good EHR software vendors seem to be working on these small form device interfaces already!

He said that he was ready to quit the second day! He persisted and by the end of the first week, got so used to the system, would not go back to paper anytime soon!

That seems to be the problem. The initial hump of adoption!

I don’t blame physicians. If I have been doing my job for years and years one way and I were to change it overnight, I would be upset and ready to quit also! But Physicians see the expense, delay and the downstream problems associated with paper records, they don’t want to go back to the way it was!

Pen and paper are very easy to use, painless from day 1 and that’s probably the way they were taught for years and years. This is like changing horses in midstream. More like swapping a horse for an automobile. Both have horsepower and that’s probably where the comparisons stop!

It may be better for consultants and EHR vendors to describe this process honestly in the beginning rather than oversell the ease with which the transition will happen! I am sure Physicians readily see the downstream advantages and are ready for it but the initial hump of adoption may be the one that scares them!

Here’s an interesting article about a survey they did among 1000 medical students. The findings are surprising!

Survey: Future docs view IT, mobility as critical

This survey found that a full 45% surveyed used the iPhone or iPodTouch and they were regularly using applications like Epocrates ,  an online application and a ready reference for drugs and diseases.  A large number of others who did not use these smartphones were planning to get one in the next year or so.

Bythe time these Medical Students finish their interships and start practicing, they will be clamoring for mobile versions of EHR, not just EHR!

Already many EHR vendors have made it easy to roll out EHR packages to Physician practices using local wireless communication and handheld tablets.  Working with a tied down computer like a desktop or a laptop with a wired network connection impdes the proper way of practice that Physicians prefer. With paper records, it is easy to face the patient, converse with them, and take notes at the same time.

With a tied down computer, it makes it awkward for physicians to turn back and forth between the patient and the computer. Sounds like a small thing, but heard that physicians really need to become comfortable with this kind of performing their work.

With wireless communication, tablets and always on connectivity to the internet, physicians that complete their education and training being comfortable with online applications like Epocrates are suddenly empowered to everyone’s benefit.

In the above article, it says that applications like Epocrates lets Interns consult the application instead of the attending physician. This may be very convenient and may provide more accurate information to Doctors in the making but as many Physicians like to say, “It may not teach them the Art of Medicine, only the Science!”.

The net net is that even as short as five years from now, we will have a crop of doctors that are much much more savvy with EHR, computing, online, wireless and handheld computing.

Many of our current stereotypes may already be outdated, only to be wrong even more in five years’ time, I am guessing!

Success or Failure of EHR adoption is often laid at the feet of Physicians. They are technology-averse, they are not comfortable with computers, etc. However it appears that everyone from the Office Manager or the person at the reception at the practice, to the Nurses and Physicians’ Assistants, to the backoffice billing persons or third party billing companies are all affected by an EHR implementation.

Paper records are so easy to use that not much attention is paid when they are used by these different people during a visit to the doctor’s office. However, when the same practice starts using EHR, you have a single Electronic Visit or Encounter record that gets started up by the person at the front office, the nurse may update the vitals section of this visit,  and then the Physician fills out the rest of the information up to diagnosis, prescriptions or tests to be performed. Then others may take over and complete the rest of the visit and the information goes to billing.

Now you can see that the entire business process needs to be mapped and addressed properly with training for everyone involved. They all need to buy in, be comfortable with the new way of doing things on the computer and start doing all of these in a coordinated manner.

The tough thing is that ANY of these interested parties can cause the failure of the whole system if they do not do their part properly in the EHR but it takes ALL of them to do it properly for it to be successful.

Thinking of EHR rollouts, especially in smaller and medium sized practices as a technology rollout is a disaster in the making! If the whole thing is not considered a fundamental change in the way business is done and then ALL the parties trained properly in doing their part with the EHR, the whole thing will fall apart!

 I loved reading Dr. Stephen R. Levinson’s book Practical EHR – Electronic Record Solutions for Compliance and Quality Care.  Dr. Levinson talks in detail about the various minor things that add up to large irritations on the part of Physicians while using EHR software and at the same time practice their medicine, looking the patient in the eye, asking questions and evaluating the responses!

It is sort of understandable! Before EHR packages, doctors used to talk to the patients without anything like a tablet PC or a desktop or a laptop coming in between them and the patient. This seems like a small thing but seems like a major irritant in EHR usability.  They used to take care of note taking and dictation after the patient visit is over or at the end of each day.

The new way of using an EHR package requires them to change fundamentally, their way of doing their job. That, and the fact that they have limited time for each patient places a lot of stress on the time they can realistically spend navigating the quirks and peculiarities of the EHR package they are implementing!

However, once they get used to the new way of doing things, they have gone over this learning curve and they are converts. One of the Physicians I talked to, had joined a medical practice after they had chosen an EHR package and completed its implementation also. He was ready to quict after two days! But he got used to this package after the third day and now would not do without the same package in other practices he visits!

Interesting tug-of-war between the User Interface and the Practice of Medicine!