I’m no expert on the topic, but now that I’ve worked with 4 electronic health records / electronic medical records (EHRs/EMRs), I’ve seen the good, the bad, and the ugly. (Usually the two latter are due to interface design and data display done by engineers, not by clinicians or nurses.) My rules first, and then my suggestions:

1. Spend time–lots of time–on the user interface. Test it with physicians. Nurses. Medical students. Techs. Administrators. People will unfortunately still buy a product with a crappy interface, but your days are numbered.
2. Let the system work for both beginners and experts. One of the things many people miss about the text-based systems when moving to graphic interfaces with icons and tabs is how quickly they could find information with keyboard shortcuts. Of couse, the keyboard shortcuts take awhile to memorize, so they’re not ideal for beginners, and make a pretty steep learning curve.
3. If you’re going to use icons, include their text equivalent. So many systems use cryptic icons designed by an intern using Microsoft Paint. Does that arrow mean go deeper? Go forward? Move to the next patient in the list?
4. Provide each user with a quick list of their most looked-up patients. I can quickly get access to all my recent patients without having to lookup their MR numbers; especially useful for consult services that don’t have a pre-assigned list of “their” patients.
5. Display lab values in the order that we human physicians think of them. Chem7s or Chem10s go in a certain order. Same with CBCs. Ask me. I’m for hire.
6. Provide a baseline lab value if a value is abnormal. If someone’s hematocrit is low on this admission, has it always been low? Is it trending down?
7. Quickly provide a way I can see a graphic trend of a lab value. It takes way too many steps currently.
8. Automatically calculate associated lab values based on abnormal labs. If someone has a creatinine greater than 1.0 or 1.1, and we know they have chronic kidney disease, and we know if they’re black or non-black, the MDRD should be automatically included. If I ask for a retic count, and the person is anemic, correct it . There are tons of clinical scenarios like this. Heck, have a clinical calculator included that pre-fills in values and spits out the answer.
9. Warn, fix, and prevent medication errors. Our current problem with medication errors, as a medical community, is inexcusable. If someone tries to prescribe metformin to a person with renal insufficiency, which is totally contraindicated, warn them, remind them, or stop them. And make the error messages helpful, not just “This medication is not allowed.” Or if they have a problem on their problem list of COPD, warn people about prescribing a beta blocker, or when ordering a P-thal cardiac scan.
10. One login for everything, and one program for everything. How secure is a system when everyone just uses a common login because they have a separate username and password assigned for the medical record, the radiology system, the echo cardiography system, the GI dictation system, and the pathology reports?
11. An alert when there’s been something new added to my patients’ chart–a new radiology report is dictated, the path report is back, etc. Or at least a chronology of the latest X changes or additions to the chart. It’s insane to have to view each menu separately, just to check to see if there are any updates.
12. Can we please, please, please figure out a way to make redundant, or “within normal limits” data hidden at first glance? With electronic medical records this is particularly a problem, because it’s so easy to cut and paste information into a chart. For a lot of things, I don’t need to know the information about the patient unless it’s abnormal. There is so much redundant information in a chart that it’s often difficult to find the important things. Hell, a frickin’ bold around pertinent information (patient with alcoholic cirrhosis hasn’t gotten his HepB vaccines) would help clinicians differentiate the really important stuff.
13. Keep track of screenings automatically. If a person’s due for a colonoscopy, or an optho exam, put up a reminder.
14. Suggest generic alternatives when prescribing meds, and list the cost next to each med–maybe it will encourage physicians to be more understanding of drug costs–for the health care system, and for the patient.

And the suggestions:

1. Could EHRs be any uglier? I’m not dealing with a freaking spreadsheet here. I could use a little color or visual design if I’m going to be staring at the thing all day long.
2. In charts with rows and rows of information, alternate the row colors (think iTunes ) . It’s a simple visual clue and prevents your eye from skipping to the wrong row when scrolling horizontally.
3. Provide one-click access to patient handouts and education.
4. Make easy, patient-friendly instruction sheets based on what you enter in the chart. If you put in a lab request for the patient to come back for a fasting glucose test in one week, that should automatically make a note that’s easy to print out with instructions, directions, time, date, etc.
5. Provide some sort of access for patients to login and see their labs. Track their weights, their HgbA1Cs, etc.

I realize that a good deal of the time is spent on putting the database and backend together; I’ve seen the schema and code for our free clinics’ medical record system. But a little more attention to the front end (which is the whole point of the electronic system) would go a long, long, long long way.

More as I think of them, and please comment and add your own.

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