EHR Review Folders – Saving Trees, Improving Care

I'm pretty sure we generate as much or more paper documents on EHR as we did in the paper charts days.

I’m pretty sure we generate as many or more paper documents on EHR as we did in the paper chart days.

On Twitter I’ve shared in many lively discussions about the struggles we have caring for individual patients on EHR systems that aren’t optimized for that purpose. Many better and more prolific writers have done a wonderful job outlining the frustration we front line clinicians face on a daily basis. Still it seems our voices have a hard time being heard.

I really don’t think EHRs really don’t have to be so difficult. Simple changes could radically change the ease of care delivery if the folks designing and implementing these systems prioritized the needs of the end users. Unfortunately, the bulk of development work these days seems to be aimed at satisfying government Meaningful Use requirements and optimizing systems for charge capture and quality metrics. Clearly EHR vendors have their hands full serving their two primary masters – the US government and hospital administrators – and the needs of those seeing actual patients are lost in the shuffle.

A couple of years ago, I hosted a couple of developers from Epic EHR for a day in my office seeing patients. We talked about a lot, but in the end I said I’d put one wish on the top of my list. I called this EHR Review Folders. Here’s a discussion of these concept, adapted from an email that outlines this simple request:

Thank you for your interest in the idea of “review folders.”  This is an old idea or mine, and I still think a good one.  I discussed this with our Epic site visitors, so I’ll include them in my email.  Let me try to describe my idea so we can try to get this promoted and (I hope) implemented

When we physicians see a patient in a new encounter or as a return after a period of time, there is a subset of the medical record that is highly relevant to us.  Most of this is predictable. We need any recent office notes from the referring MD, we need the most recent diagnostic tests.  We might wish to have the history and physical and discharge summary from any recent hospitalizations.  Every doctor has his or her own needs, but the basics are the same for all.  

In my office, our medical assistant does a chart prep prior to each scheduled visit.  She will comb through the EHR to find these relevant records, print them, and collate them into a packet that is then placed on my desk.  Since we may see 20-30 patients a day, this packet gets pretty thick and the assembly of the packet is pretty labor consuming.

It would be great if we could do away with this old process.  Unfortunately, the current EHR is not organized enough for us to quickly find relevant records on the fly.  Getting what we need can be a bit of a crap shoot because the relevant information is mixed with irrelevant information.  Only after we click on the record is it apparent whether we have what we need.  Even after finding all of the “good stuff,” there is no way to quickly go back to this record as it resides “hidden” with the other records.  In a busy office day, it is extremely challenging to click around the EHR to find all of this stuff.  Hard to find records, such as outside MD letters and other scanned documents are very easy to miss.  Most of us get frustrated, and may do an incomplete review on this basis.

My idea of a review folder would be to have a tab in the EHR in which all of the information relevant to the encounter could be collected during or prior to the encounter.  This tab would live in the patent’s EHR for as long as it is needed, and be visible to any who need it when they log in to the record.  I would envision having my MA sort records prior to the office visit by dragging and dropping the relevant records into this folder.  As I do my own prep, I will add and subtract records as well.  Some of this could be automated by having the folder collect specific types of records by date parameters or type.

A great analogy for what I envision is an Apple iTunes playlist.  On my iTunes, I can create a collection of songs into one folder that may be labeling something like “today’s run.”  I might drag and drop songs individually, or I might set up a “smart playlist” in which I specify parameters like “songs added after December 12, 2012” or “songs by the artist Ratatat.”  That list sorts what I need into one easy to find folder.

Uses for review folders could extend beyond what I’ve described.  Recently a interdepartmental complication review meeting was run for the first time in an EHR only format.  In front of a group of doctors and QA personnel, I struggled to find the relevant records in order to present a case.  Had these records been electronically sorted prior to the meeting and available on all parties Epic desktop, the meeting would have gone much better.

I find this idea conceptually logical, but I’m not sure I’ve done an adequate job describing.  I feel strongly that we could enhance patient care and save a lot of time and money if we could get this done.  I’d be more than happy to discuss further.

I’d love to hear other’s thoughts about EHR data organization. We go thorough an enormous amount of paper in my practice, purely to allow clinicians to review relevant data in an easy to access format. If some form of organized, intuitive digital data review is implemented, I could easily envision doing away with most or all of this printing. Going to a two screen solution with review data on a tablet and data entry on a bigger screen and keyboard is really an attractive option to me. Simple programming changes in our system could get us to this point. Does anyone have this sort of clinician data organization implemented in their EHR (Epic or other)? Would you find this useful? Would you help make it happen?

Jay

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4 thoughts on “EHR Review Folders – Saving Trees, Improving Care

    • Never heard anything. Perhaps we’ll see something like this in future Epic versions. We can hope.
      Recall, though, that Epic updates are kind of like old boxed software from the 1990s. Nothing changes in the program until a new version is released, purchased and installed by the hospital. With modern software, we’ve become accustomed to frequent online updates. Not so with Epic.

      • I need to update. Since this post, engineers at Epic have reached out to me. They tell me they’ve been working on this issue since our first discussions. Since this post, we’ve had a couple of teleconferences going over prototypes for the Review Folder concept.

        I suspect it will be a while until we see this functionality in action. Nevertheless, it’s great to be able to say that matters are moving the right direction. Thanks are deserved to Epic for listening.

        Jay

  1. At P&G some years go, we invented and loved a very different way of picturing all the how-to paths for successfully using very complex systems. Verbiage of traditional text instructions is reduced by 90%. Trainers and learners become more appreciative of each other because their teaching and user success becomes successful.

    My experience in tying to make the method understood and tried by government groups–like Cincinnati’s Council downtown whose members I’ve talked with–and the US Intelligence Community–has been a complete zero.

    My P&G experience includes being a servant-facilitator for 300 P&G “Invent something and Make it Happen” teams. This also has been a failed message to the intelligence Community and to the White House. It seems to me that when proposals are new–therefore not understood–that they are dismissed. There may be other reasons, of course.

    An approach I haven’t tried is to become insistent and personal against disinterest.. At age 86, I’m running out of time.

    Glad we share some common interests, Dr. Schloss

    David J. Cox djcox@fuse.net 3580 Shaw Ave. Apt 324, Cincinnati OH 45208 512 321-9009
    P&G Methods and Systems Development

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