Virtually Priceless Thoughts

It is interesting how paper-trained we are. It is often hard for clinicians to think about how to design EHR systems – particularly documentation – in a way that breaks the locality of information and the paper-bound thinking of forms and move to information. I see a lot of systems out there that promote having “digital forms” that are direct copies of paper forms — including having forms that do not fit on a single screen (because they are 8 1/2 x 11 format instead of screen shaped) and “page turning” that corresponds to the pages of the form not the GUI design of the computer.

You can see how this thinking works, when clinicians request that certain forms are available on the computer. Building forms to match paper is often the quickest technical solution and one that, sadly, get’s an easy “check” from users as they can compare the form to the computer screen for “accuracy”. Without thinking too far along the path, you can see how things get developed. Quickly scanning in the blank form as a PDF to create a background that REALLY matches the form and then adding fields on top to add text. For pizzazz add some auto-populating demographics and BOOM! It works even better than paper… Four hundred forms later and you have the electronic paper record.

The forms are important – as they are a way we consistently communicate with various groups on paper and THEY have benefits of having standard forms, just like standardized electronic user interfaces improve efficiency and safety, so do standard paper forms. But the benefit is for the end consumer, not necessarily for the clinician entering the data into the form.

Often there are better ways to design systems to support a user’s workflow while supporting the required output. There are examples of how to do this – building data capture to support clinical workflow. Clinical Decision Support (CDS) can be used to ensure that the right information is captured. Reports can then be generated to print out the appropriate forms as needed. Multiple forms would use the same data and the clinician would not have to jump around re-populating different “standard” forms with multiple pages that scroll off the screen.

The tricky part is, of course, being able to capture the data in an efficient manner that provides sufficient semantics that allows the computer to translate your documentation into the various unstandardized tick boxes for concepts developed for specific forms, something that works for CDS, and is something a clinician will tolerate.

And that takes more work and a deeper understanding of the types of knowledge that are needed without the limitations of paper.

Of course, health information systems are not the only systems that have been built from their predecessors — that is how we evolve many things. Web “pages”, for example… oh and there there were trains that evolved from horse and carriages.

Johnson et al. have published the results of a survey in Academic Medicine of recent physician graduates previously trained at Vanderbilt University on their perceptions of the use of technology. They compared graduates who were working in areas that were LESS technology enabled to those graduates who reported they were working in environments that were as or more technology enabled that Venderbilt’s Medical Centre. Those in less technology enabled environments felt less able to:

• “practice safe pateint care”
• “utilize evidence at the point of care”
• “work efficiently”
• “share and communicate information”
• “work effectively within the local system”

Based on 328 survey (60% response rate).

Interesting results that will, no doubt be interpreted in many ways — does this mean that technology makes us practice safer, more evidence based, more efficiently, etc? Or are we hampered in our training so we are reliant on these tools to do our jobs? I am sure this study will only fuel that fire.

Last summer, after some months working on a proposal, I slowly came to the realization that I needed a more clinical topic. After some deep thinking, I decided to change direction.

Now, several months later, I have successfully defended my PhD Proposal. I am developing a model to analyze and improve Continuity of Care. Care Continuity is not a new interest (I posted about it in June) and is a topic that keeps me grounded in the clinical aspects of health information science.

It has been a busy ride since I have made the decision – I have had to re-develop knowledge in several new theoretical foundations and methods, but I am excited about the study that I have developed and think that it will have a positive impact in the communities that I will be working with. Stay tuned for more details on my approach in the future.