De Novo Emr Blueprint Business Office Iii: Computer… Computer… Hey Computer…

Continuing our fantasy journeying towards a patient tending oriented EMR for main tending physicians, let’s apace recap our progress. After much ado nigh nothing, nosotros came upward amongst the next laid of requirements inwards Parts I too II:

1. System shall aid amongst gathering information from diverse sources (TBD) at the betoken of care
1. System shall aid amongst information recording at the betoken of tending (needs to a greater extent than specificity)
2. System shall recollect too convey information from external sources
3. System shall respond to all external legitimate requests for information
4. System shall receive got the mightiness to access published clinical information (consider buying)
2. System shall aid amongst synthesis of said information
3. System shall aid amongst patient-doctor human relationship building
4. System shall non brand the work harder to perform for the user

In the existent globe of software design, this would hold out a proficient house to seek validation for our idea process. We tin create that hither likewise although nosotros receive got no existent users. H5N1 recent number of JAMA Internal Medicine contains several papers dealing amongst misdiagnosis inwards main care. The Part II inwards particular, it seems that nosotros are on the right path. Although the study attributes these problems to the “relatively brief encounters” straightaway mutual inwards main care, neither the study authors nor the invited commentary dare propose that nosotros allow proper fourth dimension for each encounter. Instead, the search is on for all sorts of methodologies, checklists, “metacognitive retraining”, too finally “mandatory, structured recording too coding of presenting symptoms, rather than just diagnoses, inwards our electronic wellness tape systems” [emphasis added]. All this “without dramatically reducing efficiency”, i.e. without increasing the fourth dimension a main tending Dr. is allowed to pass amongst a patient. Here nosotros are reminded of the mutual wisdom of software developers that suggests asking users to depict their problems, but never, ever, allow them to come upward up amongst solutions.

No to a greater extent than beating some the bush then. At this betoken nosotros must tackle information recording at the betoken of care, or equally fondly known past times its practitioners, information collection (usually followed or preceded past times unprintables). Note that nosotros are insisting on usage of the term “information” instead of “data”. As far equally computers are concerned, information comes inwards entirely 1 flavor: zeros too ones. We, on the other hand, receive got larn accustomed to defining information equally structured or unstructured, where structured information is considered computable, i.e. it tin supposedly hold out analyzed past times computers. This however, is non a cloth deviation because computers tin analyze all information to diverse degrees, depending on analyzing software capabilities. Primitive software is entirely capable of analyzing information provided inwards a predefined (in the software) content too format, but equally software scientific discipline advances, computers are becoming less dependent on the user to predigest too preformat their input into the software (at 1 time, yous genuinely had to travel inwards electrical signals for ones too zeros inwards social club to receive got the figurer create anything useful). So the structured vs. unstructured information debate is all nigh yesterday’s computers vs. tomorrow’s computers. We volition create our imaginary EMR for tomorrow’s computers, some of which are already hither today. This is our start engineering decision: We are requiring a contextual parser too processor of information that tin convey input from all known modalities (keyboard, mouse, microphone, camera/video, stylus, touch/gestures, too electronic interface). Here nosotros call to our #1-d requirement, which seems pertinent, too work an imaginary organization analyst to telephone yell upward IBM.

We soundless receive got to pattern the forepart cease though, hence information from the come across tin hold out transferred to our hopefully smart processor. We are reminded of our glossa inwards cheek #4 requirement (or constraint really), too inwards social club to fulfill this requirement, nosotros volition demand to evaluate how our users currently document encounters, amongst the agreement that a large number of physicians are non using computers to document, too an fifty-fifty larger number of doctors utilization computers too loathe doing so. Hence, our gilt standard, or limiting factor, for #4 is the paper chart. But fifty-fifty the paper nautical chart comes inwards all sorts of shapes too flavors:

1. Blank canvass of paper allowing gratis manus documentation
2. Structured forms amongst predefined questions, which may comprise 1 or a combination of:
1. Questions amongst predefined multiple selection answers
2. Open ended questions 
3. Room for gratis manus written answers
4. Room for gratis manus notes
5. Anatomical drawings for annotation
3. Dictation devices allowing transcription of vocalisation summaries into the chart
4. Abstracted lists of factors deemed of import (medication list, work list, allergies, etc.)

Simple electronic versions of charts receive got non done much other than supercede manus writing amongst keyboard typing too mouse clicks. For physicians who type good too are relatively comfortable amongst computers, or those who routinely dictated everything, these unproblematic EMRs did non violate our #4 requirement. The to a greater extent than elaborate EMRs, took upon themselves the noble work of speeding upward the documentation work (years agone in that location used to hold out speed contests betwixt EMRs at merchandise shows). And they did that past times using electronic stilts. If yous always tried equally a child to master copy circus stilts, too hence yous know that they allow yous to convey much longer steps too comprehend a lot to a greater extent than soil inwards shorter times. The caveat though is that yous volition most probable experience several bruising falls piece yous develop yourself to utilization the stilts, too that yous tin entirely utilization them for brusk periods of times on perfectly apartment surfaces. The flexibility built into your legs too feet past times millions of years of evolution, enabling yous to consider too respond to details too uneven soil is pretty much gone, hence if yous essay to utilization circus stilts inwards everyday life, yous volition likely honour it to hold out a handicap rather than an advantage. What nosotros genuinely demand is shoes. Walking shoes, hiking boots, lawn tennis shoes, cleats, basketball game shoes too maybe ballet slippers, all inwards different sizes too widths, colors, materials, back upward too toll ranges. For main care, nosotros probable demand a proficient couplet of cross trainers.

Most software programs tin hold out divided into 3 parts, or layers: the information layer, where all the information is stored, the display layer, which is what users consider too interact with, too the line of piece of work organization layer, which controls the application too is the de facto processing encephalon of the software. As is the example amongst people, the beauty of software comes from within. Usability of software products is much to a greater extent than dependent on the intelligence too abilities of the controller encephalon than it is on the lipstick of the display. The things that are causing heartburn to electrical flow EMR users were created exactly to compensate for the feeble brains of the software. Since nosotros already made a engineering conclusion to splurge on the best too most sophisticated software encephalon available, nosotros volition abstain from stealing valuable fourth dimension from the patient too from the fine art of observation. Additionally, nosotros volition non effort to shorten the fourth dimension required for a physician to tape observations inwards brief too patently linguistic communication (as hard equally that may be). We banking enterprise complaint hither that dissimilar other professions, historically, physicians did non employ stenographers during patient encounters too recording observations was real much component division of the scientific discipline of medicine. Therefore our information gathering user interface volition receive got the next features too functionalities available:

1. Ability to tape too interpret to text all verbal telephone commutation during a patient encounter. This includes the mightiness to position the parties engaged inwards dialog too appropriately assort the information equally objective or subjective (patient reported), too the mightiness to convey addenda to an come across through multiple modalities (in example yous are wondering, this technology already exists).
2. Ability to convey electronic input from all medical equipment used inwards the practice, without whatever human intervention.
3. Ability to create electronic forms dynamically, from scratch or based on scanned paper forms, including drawings, too mightiness to modify these equally needed.
4. Ability to convey input from keyboard, mouse, pen/stylus too vocalisation for all cast fields without exception too without prior setup or notice.

When correctly combined the finally 3 functionalities should create no to a greater extent than than carry the paper nautical chart methods of documentation to a figurer screen, zip to a greater extent than than a glorified Microsoft Office for medicine, piece the most hard functionality inwards #1 should furnish our intelligent processor the context necessary to augment too perchance inwards due course of study supercede the demand for deliberate documentation. Note that nosotros are inwards no agency restricting our users to a especial subset of their natural language. Somewhere deep inwards the bowels of our contextual processor in that location volition hold out vocabularies, ontologies, terminologies too synonyms, but our imaginary evolution squad does non believe that it is the responsibleness of the user to adjust to the machine. We are on a quest to develop intelligent machines, non robotic people.

I tin practically consider the raised eyebrows of those who desire to measure, analyze too furnish clinical advice to practicing physicians, contending that most EMRs neglect to hold out useful exactly because they are just electronic paper charts. Strangely plenty the much touted electronic media too all its blogging/social media offshoots are doing quite good inwards spite of existence just electronic newspapers too pamphlets, too this revolutionary transition would receive got failed miserably if nosotros required authors to create content from dropdowns too checkboxes. The truthful mightiness of transitioning paper to electronic media comes from the inherently amend accessibility too portability of electronic media, too from the mightiness to insert always improving computerized synthesis underneath the familiar expect too experience of paper. As nosotros motion on to our #2 requirement too define our specifications for synthesizing too serving information, it should larn apparent that although inconveniencing the user is 1 solution to the real hard work of information synthesis, it is most probable non the best solution.

We did non comprehend hither inwards whatever item the telephone commutation of information imposed past times 1-b too 1-c, since unproblematic technologies for both functionalities be today, especially if nosotros don’t insist on specific structures for our exchanged content, too nosotros are not.  Since our 1-a requirement proved to hold out a handful, too nosotros entirely scratched the surface inwards most full general terms, nosotros volition postpone give-and-take on requirement #2, which includes non entirely intelligent synthesis of information, but also serving the results to users at the right fourth dimension too inwards the right place, to Part IV, too nosotros volition add together Part V to bargain amongst the fuzzy requirement expressed past times #3. We receive got a long route ahead of us, too this is just brand believe design...