I came across a recent interview of Dr. Peter Stetson, CMIO, Columbia Doctors, in which he discusses, in part, the "next generation" of electronic health records (EHRs) (see: HIStalk Interviews Peter Stetson, CMIO, Columbia Doctors). Columbia Doctors is a multi-specialty physician group of about 1,000 physicians in New York. The company has about 150 practice sites in the Tri-State area of New Jersey, Connecticut, and New York, with its primary base at Columbia University Medical Center. Here's the portion of the Q and A interview that interested me the most:
Q: What should the next generation of EHRs do that the current generation doesn’t?
A: I think that the challenges that we face are specifically in coordination of care. If you imagine trying to infuse an EHR with the principles of Patient-Centered Medical Home and the Accountable Care Organization, it’s going to require workflow solutions that enable communication and coordination. I see elements that have Web 2.0 and 3.0 technologies being major factors in that design....You may have read David Bates’[articles] where he’s talked about trying to improve diagnostic accuracy, improve coordination of care, and try to get the EHRs to move in that direction (see: Using information systems to measure and improve quality). I wholeheartedly support that. I think that’s where a lot of the vendors are already looking....The second thing that I think is going to become more infused into EHRs, and is something that we’re working on here at Columbia, is to enable the representation, the manipulation and physician understanding of personalized medicine concepts — genomic and pharmacogenetic data. I’m not aware of many EHRs that support that as structured data or actionable data that physicians can use to make decisions right in the EHR....[A]s HL7 special interest groups and clinical genomics start to have their standards permeate the health IT space, I think we’re going to start to see ways of collecting and manipulating genetic and pharmacogenetic data in EHRs in ways that we haven’t seen today.
The connection between the EHR/EMR and diagnostic accuracy is a topic of great interest to me. I have previously commented on the topic of the high mortality associated with diagnostic adverse events (DAEs) (see: New Attention Being Directed toward Diagnostic Adverse Events (DAEs)). Here's a passage from that note;
The causes of DAEs [diagnostic adverse events] were mostly human, with the main causes being knowledge-based mistakes and information transfer problems. Prevention strategies should focus on training physicians and on the organization of knowledge and information transfer. We can do little to correct a "knowledge problem" on the part of a clinician who has received timely and correct diagnostic reports from pathology and radiology. However, there is much work to be done in terms of timely reporting from these two diagnostic services and also better integration of the diverse diagnostic reports from them.
As emphasized in this paragraph, the contribution of the major diagnostic services (pathology, clinical labs, and radiology) to diagnostic accuracy, and the reduction of DAEs, will consist of timely and accurate reporting from the LIS, RIS, and PACS to the EMR plus, at some later time, integrated diagnostic reporting. By this latter term, I mean that diagnostic specialists (i.e., pathologists and radiologists) will collaborate on challenging cases and render diagnoses back to clinicians based on a multiplicity of information inputs. These would include imaging studies, molecular diagnostic studies, and the analysis of stained thin tissue sections.
A key question, though, is how are we going to arrive at the Next Gen EMR described by Dr. Stetson that will include "workflow solutions that enable [efficient and effective] communication and coordination." In my mind, this will not be possible without an effective set of computerized rules operating in the background of EMRs that automatically manage the majority of such communication and coordination tasks. For example, if there is any significant change in the status of a patient or new diagnostic information acquired, the key members of the team caring for the patient should be automatically notified. The development and testing of such a comprehensive set of rules for an EMR is a daunting task. Moreover, the tendency when deploying such rules in the past has been to err on the side of distributing more information rather than less for medicolegal reasons. This results in information overload for the recipients and causes nurses and physicians to turn off the alert system or ignore the alerts, making the system meaningless.
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