What does a better EHR look like?

I tweeted recently "It is sad that electronic health records are designed around billing, not optimal patient care, utility, provider efficiency or satisfaction" (https://twitter.com/weldeiry/status/916817360828420096).

I also tweeted "Even within the same hospital multiple systems do not communicate and data does not go back and forth except through the human input" (https://twitter.com/weldeiry/status/916815710118203392).

This is in an age where technology has advanced to allow us to do better, even if some of it is hyped (https://twitter.com/weldeiry/status/916913178516258816).

What could an electronic health record look like and how could it function to better facilitate patient care? The below can be accomplished while maintaining patient privacy.

1- First of all, it should be portable and easily communicated. We've had portable document files since the early 1990's (https://en.wikipedia.org/wiki/Portable_Document_Format) but we still do not have the equivalent for a health record, the PHR (portable health record). While I came up independently with the idea, I see it has been thought of previously (https://participatorymedicine.org/epatients/2011/08/how-about-phr-portable-health-record.html). Still in 2017, we do not have PHRs beyond the xerox machine, fax, and CDs.

?It should be easy. We have USBs, clouds, email. All can be very private and confidential. LinkedIn has for years had a nice feature of generating PDF records of user profiles on demand. The technology certainly exists to make content available and portable for more efficient sharing.

2- The EHR should be sync'd. Just like all your electronic devices are now automatically sync'd, so should the EHR. Basic changes to the EHR components should be automatically updated and in sync and one can go back in time. The EHR is easily accessible from anywhere and always up-to-date with the latest data.

3- The PHR should be easily incorporated into the workflow in a new environment when a patient sees a new doctor or moves their care to a different health system. This too should be seamless. The PHR is owned by the patient in whose interest it serves. As such, the patient has access at all times and authorizes the sharing and use.

4- The EHR should be readily available. Not only should it be sync'd but it should be carried on phones because almost everyone has a cellular phone now. See #1 and #2.

5- The EHR should have seamless data entry. It should be easy for a clinician to enter data into the EHR. There are various types of data that often involve different media. The process should be seamless. This could use barcoding or pointing a chip at a phone or other device. A thumbprint should be all it takes; may be in the future a retina scan or face recognition. Words can be directly dictated or typed. If a test is ordered, the result (CT scan images, histopathology, endoscopy, gene tests, blood tests, culture results) should be the main focus and it should be incorporated within the rest of the clinical summary for easy viewing.

6- Every medical student and trained clinician knows the relevant fields and data elements because the profession has developed over thousands of years. Clinicians are already familiar with what a patient summary, problem list or overview should look like. Thus with portability, there is an expectation for what is and needs to be communicated.

Companies or organizations that want to help solve the problems should spend more time in clinical environments and speak with clinicians. In the end clinicians need to spend much less time clicking at computer screens. Clinicians can communicate very efficiently verbally and the technology exists to capture, translate as needed, verify and execute a clinician's intent in a way that can be safe and save time.

In the EHR or PHR, one expects to see the HPI (history of present illness), PMH/PSH (past medical and surgical history), SH (social history including occupation, habits, diet, and wishes), FH (family history including pedigree or a link to one that can be edited), medications, allergies, recent physical exam, review of systems, assessment and plans including by list of problems. An up-to-date problem list should be readily viewable within such a record. Links to prior hospitalizations or medication records, e.g. prior chemotherapy regimens and doses can be easily incorporated.

The EHR can easily contain actual sounds (from cardiac, lung or abdominal exam), images (patient's photo, photo of rashes, swellings, skin lesions, X-rays, EKGs, endoscopy images, CT scans, ultrasounds, MRIs, PET scans, key frames from angiography, digital pathology), laboratory and molecular data (data from germ-line testing and tumor profiling in the case of cancer). Some could be available through links. It is important to note that digital pathology has yet to be incorporated into the EHR even though the technology to do so has existed for decades. The patient's main doctor is in a good position to determine what would best constitute a summary beyond what would be otherwise required components. There is a bit of an art in deciding what to include. One slice of a CT or PET scan can often tell a major part of the story.

Gathering data should be easy from probes hooked up to phones (medgadget) and incorporation into the record should occur in real-time without any time being wasted logging into many different systems and platforms and clicking numerous times to achieve simple goals. Every minute wasted at the computer adds up to time less spent with patients.

There is a need to regain some of the art of medicine that arguably has been lost with formatting and functionality of current records, processes and time staring at computer screens. The data fields should be meaningful and say something relevant about the health of the patient. The record could even include a dated brief video restating a clinical summary and plans. This can be communicated in 2-3 minutes for most patients.

Every medical student and clinician knows what a case report looks like. Why can't the EHR generate a PHR on demand that can be readily available and shareable. It could distill hundreds or thousands of pages but serve as a readily available resource for clinicians to take better care of patients. For most patients such a record can be no more than 4-5 pages that can be quickly reviewed.

Associated data such as pathology, radiology or surgical operation reports can be linked for more in depth viewing.

A simultaneous challenge is to simplify the work of clinicians in ordering tests, prescribing medications, discharging patients from the clinic or hospital. Added complexity comes with participation of patients in clinical trials. There is much to be done there too with making systems more user friendly and interactive, but it would help if the basic EHR is improved.

What is the expected pay-off for improving health records? Better, safer, more efficient, more personal patient care with less time wasted clicking and ending up with more optimal records that are easy to share.