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EHR Proliferation Hurts Physician Workflow

Doctors are being forced to pull data out of multiple EMRs -- plus use phones and pagers -- to care for patients. This context switching slows down work and frustrates the goal of electronic health data.

Technology Declares War On Cancer
Technology Declares War On Cancer
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This year's medical student graduating class will be the first group of physicians trained without paper-based medical records. These students understand how electronic health information is supposed to be better than paper, but what will they encounter in reality? Most doctors and other healthcare workers already in the trenches are familiar with less-than-positive scenarios.

Let's say a Mr. Jones is admitted to the intensive care unit with a possible cardiac condition. You spend close to one hour reviewing his medical history in the ER. Concerned with his EKG tracing and abnormal electrolytes, you admit him to the cardiac intensive care unit.

Later, the cardiac intensive care unit pages you. The charge nurse in the ICU doesn't know why you were paged and tracks down Mr. Jones's nurse. She received a call from the lab about an elevation in his troponin level and wanted to advise you of his slowly declining blood pressure and increase in heart rate. She also mentioned that his EKG and chest X-ray have been completed and are in the "system." You review the findings to create an assessment and plan.

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Your computer requires you to connect to the VPN client and log into the hospital system. Once a secured connection has been obtained, a gateway into the electronic medical record (EMR) system enables you to access his labs. You see nothing ominous, so you navigate to the nurse flow sheet.

Navigating EMR gulags
You begin dealing with the technical difficulties of the EMR and the disparate pieces of data that summarize Mr. Jones's physiologic state. Closing that EMR, you next connect to the radiology management EMR system to view his chest X-ray. A similarly slow process allows you access to his EKG, stored in yet another cardiology management EMR. After navigating three different EMRs, you make a diagnosis and prescribe a course of antibiotics. You enter the orders into another EMR. Data is stored, transferred and acted upon in disconnected and unrelated systems.

(Image: Ardonik (Flickr))
(Image: Ardonik (Flickr))

In another scenario, a healthcare provider might receive a piece of information, such as a set of vital signs or the result of a lab test. If the information raises a question or requires a decision from a physician, the provider calls the doctor. The contact is often a manual one, using the antiquated paging system or some technological surrogate such as text messaging or a phone call. Regardless of the contact method used, doctors are not always in a position to take a call or page. That person might not even be the doctor for that patient anymore.

The dizzying pace of context switching
Although the specifics vary with disease and patient, this flow of work -- even in today's EMR-centric health systems -- is commonplace. The issue is context switching. In the cases described, the nurse's and physician's workflow is interrupted because they need to switch contexts from current tasks to respond to the new issue.

When the doctor receives the call, message, or page, the first context switch is required. The doctor gets notified on a pager, but has no clue regarding the urgency of the page unless an alphanumeric message comes through. The question being asked often requires tracking down additional EMR-based information in order to make a decision. This leads to another context switch, in which the doctor has either to request additional information from the nurse or log into the EMR to gather recent trends or lab data.

These multiple switches between unconnected EMR systems and personal mobile communications devices disrupt everyone involved. They require us to hold multiple, disconnected pieces of patient information in our minds while proceeding to gather information from the next source. It hurts

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efficiency, duplicates work, and introduces errors or misses information altogether that might have led to a better outcome.

To address these issues, we need change how we work with the stream of information for patient care. Despite some improvements in EMR technology, healthcare providers still need to search for information in these systems similar to a Google search. Pulling information out of various healthcare data management systems or from different portions of a single EMR takes time away from patients.

The problem is not a lack of technology to allow for data conversion. Medical pros need the simple type of push technology that is used to flag an article on newspaper websites and to receive notifications when a related article of interest is published. In addition, the ability to access related information in a single application or seamlessly move between applications is needed. This will reduce context switching and already exists with smartphones and other mobile computing platforms.

To make this a reality for healthcare providers, a system consisting of multiple pieces is required, but individually, these pieces already exist. To build a more effective and efficient workflow in healthcare requires the integration of messaging with data accessed from disparate and disconnected health databases, all wrapped in a single-view, secure platform, accessible by various smart computing devices.

Solutions available
What is frustrating to physicians is that pieces for creating such a system already exist. One security software leader has developed a mobile security platform that enables secure transmission of data between mobile applications and Web-based storage repositories, including servers, Web pages, and other data portals. Tapping into this platform or other security wrappers will be significant given the sensitivity of the information being transferred. Although secured SMS messaging is available, it needs to be integrated with EMRs and provide push notifications to reduce or prevent the context-switching issues that lead to distraction, inefficiencies, and potential errors.

Beyond the selfish interest of physicians to improve their comfort level, the workflow issue is about patient safety, quality of care, and, finally, bridging the gap between EMRs and better patient outcomes. There needs to be a shift to a patient-centric approach that connects all the points.

We need collaborative EMR systems that work like medical pros and include "smart" analyses that can interpret data. The information needs to be delivered to those who need it, when they need it, all in one place. Add voice-to-text capability to save valuable physician and nurse time and help end miscommunications.

A system that reduces context switching and promotes smart alerting and the pushing of relevant patient information to medical pros will increase patient satisfaction, address quality and timeliness for patients, and allow for more proactive care and patient follow-up.

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Thanh Tran, CEO of Zoeticx, Inc. also contributed to this column.

A board-certified anesthesiologist, researcher, medical educator, and entrepreneur with more than 15 years of experience in healthcare, Dr. Voltz has been involved with many facets of medicine. He has performed basic science and clinical research and has experience in the ... View Full Bio
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