A new way to make EHR notes

At Innovation Symposium, rethinking the fundamental purpose of documentation
By Mike Miliard
08:35 PM
doctor using EHR

Greg Shorr, MD, has some issues with electronic health record user experience.

Generally, he's not a fan of how little they've evolved in recent years: Most systems "pretty much look the way they looked at the turn of the century, in 2000," he says.

More specifically, he has a problem with an original sin of EHR design: the fact that "we have elements in EHRs carried over from days of paper."

That skeuomorphism – tabs, notes – sells short the potential for digitized patient records, says Shorr, chief medical information officer at Apex Data Solutions.

Shorr has more than four decades of EHR development experience; he was on the founding team of the Indian Health Services' customizable health information system, Resource and Patient Management System (RPMA) and is veteran informaticist.

In coming years, he sees huge potential for improving the EHR interactions of physicians and patients alike. Speaking at the day-long Innovation Symposium at HIMSS15 on Sunday, he showed how he's trying to upend the way EHRs are set up and "build a user experience that's very different from the one today."

Shorr's work at Apex is focused on digital documentation at the point of care, specifically physician notes within outpatient EHRs – "where the rubber meet the road."

The purpose of an EHR is "to tell a patient's story," he said. The purpose of clinical documentation is "to fill in knowledge gaps." But too often, neither of those goals are being fulfilled as clinicians frantically type away, filling their EHRs with volumes of disjointed patient notes.

One design imperative is to develop a new approach that replaces notes with stories.

"The human brain is wired for stories," said Shorr. "A note is a snapshot that lacks the dimension of team and time." He added that such "fragmented" documentation is "archaic and almost totally irrelevant, except for billing purposes."

By using digital pens and smart paper, for instance, a clinician can "look at note, update it, mark it up" – addressing the knowledge gap and telling a more detailed narrative.

But this is not just about providers. Shorr has the patient in mind too, and foremost in his design thinking is finding ways to "minimize intrusion of technology" in clinical encounters.

"We've lost contact," he said, as he projected a widely circulated image, first published in the New England Journal of Medicine. Drawn by a seven-year-old, in crayon, it portrays her visit to the doctor: As she sits on the exam table, the doc is isolated in the corner, looking away, hunched over a computer.

It's a "poignant" drawing, said Shorr, that illustrates "where we're headed with documentation" unless some big changes – to technology and to process – can be made.

"The patient experience is inextricably tied to the user experience," he said, noting that there's hard evidence that shows that there are measurable clinical benefits – improved adherence, improved outcomes – when the doctor/patient relationship is more person-focused.

In the meantime, he worries that some of the next generation of doctors, weaned on technology, "are growing up in an asynchronous environment."

Rather than focusing on the screen and the keyboard because that's what EHRs demand, "I want (physicians) to look me in the eye and observe what's going on with me," said Shorr.

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