As a result of the 2.5 decades I spent creating ComChart EMR, I have learned a lot about which features are useful in the exam room and how to design an EMR so that it facilitates the user ability to provide medical care to their patient. As Judy Faulkner, Founder and CEO of Epic said, “Good software is art.” To this, I would add that it is only possible to create a well designed EMR if a practicing physician is intimately involved in both design and programming of the EMR.
Now that many of my former ComChart users have had to leave ComChart EMR for one of the large commercial EMRs, I have come to realize that some of these large EMRs lack features which were in ComChart EMR and which the former ComChart physicians wished were in their new EMR. In an attempt to improve the quality of these large, commercial EMRs, I have created the below list of features which, in my opinion, should be in all /most EMRs.This list is not intended to be comprehensive and it is totally subjective. While I expect that some of the items will be in some EMRs, I am certain that they are not in all EMRs.
As this list is a bit long for a typical posting on The Health Care Blog, I will present the half of my list below, which will include suggests regarding the Lab section and the Progress Note section of the EMR. The second posting on The Health Care Blog will discuss other suggested features for EMRs.
A Universal Truth about EMR design
It is essential that when all EMR features are incorporated into the EMR so that 1) they make their presence obvious to the user at the point moment in the clinical encounter and 2) the feature should be presented to the user in a manner which make it intuitively obvious how to utilize the feature or at least how to learn how to use the feature without being referred to a manual or told to attend a “training class” or call “technical support.”
Lab feature:
There should be button that causes the EMR to only display all the abnormal lab test results and then gives the user the ability to sort the resultant list by test name, test date or any other parameter which is available. This can be invaluable when trying to understand the etiology of a patient's symptoms.
Lab feature:
The physician should be able to display any subset of a patient's lab results, with the option to omit individual results, re-sort the displayed data (by date, value, name) and be able to export the data in cvs or Excel format.
Lab feature:
It should be possible for a physician to create a chart of lab tests, on the fly, which include any combination of tests from the patient's existing labs. It should be possible to incorporate this lab chart into a Progress Note or print out the chart for the patient.
Lab feature:
It should be easy for the physician to create an association between incoming test results (or LOINC value) and specific medicines so that when a incoming lab result is filed, the associated medication name appears alongside the file results. For example, every time a cholesterol result is filed, if the patient is on a statin, the name and dose of the statin will appear alongside the test result. In addition, this field should be accessible to the physician so they can add/alter the information as they feel is necessary. Other potentially useful associations are HBA1c and diabetic medicines, potassium and ace inhibitors, Vitamin D and ergocalciferol, etc. With this association incorporated into the lab results, it should be possible, with one click, to create lab charts which include the concurrent medication information, like this…
Lab feature:
Within the labs, it should be immediately obvious who ordered a test and to whom a copy of the test was distributed.
Progress Notes:
Physicians should be able to create a chart of any lab test results, from within the Progress Notes, by simply typing some sort of macro like “\\Lab test name.” This type of feature reduces unnecessary navigating around a patient's chart and improves a physician's work flow.
Progress Notes:
A physician should be able to add selected free text from the Progress Notes to either the Problem List, Medicine list, Allergy list, Family History or Old Problem list by simply highlighting the data and clicking a single button. This will reduce the need for “double entry” of data.
Progress Notes:
There should be a free text field on the Progress Note layout where a physician can enter information that is not officially part of the patient's patient chart and will never be exported or printed. This feature would allow a physician to write note to themselves like “Daughter wants issue of her mother's depression discussed at the mother's next visit, and daughter does not want to be identified.” Prior to the creation of EMRs, physicians would attach a piece of paper to the outside cover of the patient's manila folder.
Progress Notes:
The physician should be able to search all of an individual patient's free text Progress Notes for a word or phrase. It should also be possible to search a subset (or all) of the entire EMR's free text Progress Notes for a word or phrase. This can be very useful when doing population searches or when trying to find a particular patient whose name is unknown.
Progress Notes:
The user should be able to print out any (or all) sections of a patient chart with no more then 2-3 clicks and concurrently print out a pre-addressed envelop. The design of this process should give the user the ability to have complete freedom to decide which sections of the chart will be included in the print-out, down to the level of individual test results and Progress Notes. This can be very usefully when creating referral letters.
Progress Notes:
The physician should easily be able to create template Progress Notes without the need for an IT person. These can be constructed from a series of “macros.” Examples of Progress Note “macros” should include:
ACTUAL DATA which will appear in the Progress Note MACRO
HISTORY AND PHYSICAL h&p or H&P
Today's date TodaysDate
Time GetCurrentTime
Patient name PatientName
Patient's nick name GetPatientsNickname
Date of Birth GetPatientDOB
Patient age on date of office visit GetPatientAge
Problem list (comma separated list) GetProblemList
Problem list (one Dx per line) GetParagraphProblemList
Problem list (one Dx every 4th line) GetParagraph2ProblemList
Diagnosis list(comma separated list) GetDiagnosisList
Diagnosis list (one Dx per line) GetParagraphDiagnosisList
Diagnosis list (one underlined Dx every 4th line) GetParagraph2DiagnosisList
Diagnosis list with dates (one Dx per line) Get_ParaProblemListWithDates
Medicine list (comma separated list) GetMedicineList
Medicine list (one Rx per line) GetParagraphMedicineList
Old Medicine list GetOldMedicineList
Allergy list (comma separated list) GetAllergyList
Allergy list (one Rx per line) GetParagraphAllergyList
Flowsheet data (most recent) GetFlowsheetData
Flowsheet data (all) GetAllFlowsheetData
Flowsheet data past due GetPastDueFlowsheetItems
Old Problem list (comma separated list) GetOldProblemList
Old Problem list (one Dx per line) GetParagraphOldProblemList
Family diseases (comma separated list) GetFamilyDiseases
Family diseases (one Dx per line) GetParagraphFamilyDiseases
Social history GetSocialHistory
Habits and Risk Factors GetHabits&RiskFactors
Review of Systems GetReviewOfSystems
Most recent vital signs GetMostRecentVitalSigns
Chart of vital signs (chart of all data) GetChartOfVitalSigns
Chart of vital signs from last 3 years GetChartOf3yearsVitalSigns
Saved History GetSavedHistory
Saved Physical exam GetSavedPhysicalExam
Saved ROS GetSavedROS
Saved Procedure GetSavedProcedure
Saved Treatment Plan GetSavedTreatmentPlan
Clinical Summary (Probs, Meds, Allergy, FSH, habits) GetClinicalSummary
Lab results (all) GetAllLabResults
Lab results (all) data results only GetAllLabsDataOnly
Lab results (< 12 month old) Get12mLabResults
Lab results (< 12 month old) data results only Get12mLabsDataOnly
Lab results (< 6 months old) Get6mLabResults
Lab results (< 6 month old) data results only Get6mLabsDataOnly
Lab results (< 3 months old) Get3mLabResults
Lab results (< 3 month old) data results only Get3mLabsDataOnly
Lab results (< 1 months old) Get1mLabResults
Lab results (< 1 month old) data results only Get1mLabsDataOnly
Lab results (≤ 7 days old) ) Get7dLabResults
Lab results (≤ 7 days old) data results only Get7dLabsDataOnly
Lab results (most recent labs) GetMostRecentLabResults
Lab results (most recent labs) data results only GetMostRecentLabsDataOnly
Radiology reports (Entire text of all) GetXrayReports
Most recent radiology report GetMostRecentRadiologyReport
Radiology summaries (Recent, first) GetRadiologySummaries
Radiology summaries(Oldest, first) GetChronologicRadSummaries
Most recent radiology summary GetMostRecentRadSummary
Radiology summaries < 1 month old Get1mXraySummaries
Radiology summaries < 3 months old Get3mXraySummaries
Radiology summaries < 6 months old Get6mXraySummaries
Radiology summaries < 12 months old Get12mXraySummaries
Radiology reports < 1 month old Get1mXrayReports
Radiology reports < 3 months old Get3mXrayReports
Radiology reports < 6 months old Get6mXrayReports
Radiology reports < 12 months old Get12mXrayReports
User's name MedicalProvider
Name of Primary Care Physician PCP name
Name of Referring Physician Referring MD name
Progress Note ID number PGNIDNumber
Associated clinicians (Includes PCP & Referring MD) GetAssociatedPhysicians
Chart of patient's CBCs LabChart:CBC
Chart of patient's Electrolytes LabChart:Electrolytes
Chart of patient's Lipid Profiles LabChart:LipidProfile
Chart of patient's INRs LabChart:INRChart
Chart of patient's Lipid Profiles LabChart:LipidProfile
Chart of patient's Liver Function Test LabChart:LiverProfile
Chart of patient's Thyroid Profiles LabChart:ThyroidProfile
List of diagnostic tests pending GetListOfTestsPending
List of prescriptions written today GetPrescriptionsWrittenToday
Associated billing claims information GetBillingClaimsData
Copayment of Primary Insurance GetPrimaryInsurance
Copayment of Secondary Insurance GetSecondaryInsurance
Copayment of Primary Insurance GetCopayPrimaryInsurance
Copayment of Secondary Insurance GetCopaySecondaryInsurance
Get all CPT names modifiers codes GetAllCPTNamesModifiersCodes
List of all CPT codes GetAllCPTCodes/Names
Most recent CPT code (CPT1 from last visit) GetLastCPTCode/Name
List of Diagnoses with ICD codes (one line) GetDiagnosesWithICDCodes
List of Diagnoses with ICD codes (paragraph) GetParaDiagnosesWithICDCodes
Get patient's next appointment GetPatientsNextAppointment
Progress Notes:
The physician should be able to easily create personal “macros” where the physician types an appreciation and the EMR replaces it with the associated text information. For example; the user might create the macro “\paoa” which when entered into the EMR's Progress Note immediately gets replaced with “Patient aware of above”. Or the physician might create a macro “\gcl” which is immediately replaced by
“PAST MEDICAL HISTORY:
PROBLEM LIST:
GetParagraphProblemList
MEDICINE LIST:
GetParagraphMedicineList
ALLERGY LIST:
GetAllergyList
RISK FACTORS:
GetHabits&RiskFactors
SOCIAL HISTORY
GetSocialHistory
FAMILY HISTORY:
GetFamilyDiseases
PHYSICAL EXAM:
GetVitalSigns”
And then, the “standard” macros (like GetParagraphProblemList) get replaced with the actual patient data. All of this will make it easier for the physician to minimize the time they spend “charting” and give them more time to interact with their patents.
In my next posting on The Health Care Blog, I will discuss some other features which I believe should be in all EMRs.
Feel free to add to this list. Maybe the large EMR vendor will read your suggestion and add the feature to your EMR.
Hayward Zwerling, M.D.is the founder of ComChart, a now defunct EHR program. He practices with the Lowell Diabetes and Endocrine Center.
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