Theory
In 2009, Charles P. Friedman, PhD proposed and published a proposed fundamental theorem of biomedical informatics in the Journal of the American Medical Information Association.
Contained in this brief paper was a simple diagram.
Per Dr. Friedman, this diagram is meant the convey the following concepts:
- A person working in partnership with an information resource is greater than the same person unassisted.
- The “plus” symbol conveys an interaction between the person and the resource (usually a computer).
- The parentheses represent a “bonding” between the person and the resource and suggest that the interaction is shaped by the environment surrounding its use.
- The “greater than” translates to “better” (i.e. whatever task the person is attempting to complete is completed better with the resource than without).
And he goes on to describe 3 corollaries:
- Informatics is more about people than technology and information resources must ultimately be built for the benefit of people.
- In order for the theorem to hold, the resource must offer something that the person does not already know.
- Whether the theorem holds depends on an interaction between person and resource, the results of which cannot be predicted in advance.
Seems pretty basic doesn’t it?
Reality
As an emergency physician, I receive a couple of monthly papers/newsletters and regularly peruse online sites with healthcare opinion pieces (NYT, KevinMD, etc.). I’ve noticed a trend in the articles I was seeing and reading, the titles of which should be revealing.
- “The EMR Dilemma: Hidden in Plain Sight”
- “Why EMRs Don’t Work for Eps”
- “Physicians must demand Accountability from EMRs”
- “Sharing medical records won’t work”
- “Both physicians and patients need to stop viewing technological tools as threats”
- “The healing patient-physician analog relationship is in critical condition”
- “We need to find the Steve Jobs of health care tech”
- “Physicians must reclaim the medical record”
- “Health care documentation is terrible. Here’s why.”
- “The administrative monstrosity of medical documentation is out of control”
And so on…piece after piece about the state (or failure) of EHRs and medical informatics in general.
The power of Freidman’s theorem has to do with its simplicity, and it can help us evaluate the potential problem areas of our current EHRs. The theorem only has 4 components (person, interaction (user interface), information resource, environment) so it must be the case that the problem rests within at least one of them. The person is the same on both sides of the equation so let’s rule that one out…leaving us with only three points of evaluation.
- Perhaps the EHR back end is okay but the user interface is bad enough to counter any positive effects. This is most certainly at least partially correct.
- Perhaps the EHR is simply not a valid clinical information resource. Given the amount of time clinicians spend deriding an EHR’s focus on coding and billing this has at least some weight. Perhaps it should be called an EBCS (electronic billing and coding system).
- Lastly, perhaps the overall healthcare environment is enough to defeat an otherwise net positive benefit of an EHR. With the extreme focus on patient satisfaction, billing and coding, quality measures, malpractice avoidance, etc. etc. etc. it might just be the case that any electronic system that has to serve every one of these masters is destined to be unwieldly, unfriendly, and unloved.
Interior Design
Obviously, all three of the above potential problem areas are correct to some degree, but we can thank Dr. Freidman for his conciseness as the problem and solution must lay somewhere in these three elements.
So what? Here’s what.
Show of hands…who thinks billing and coding requirements are substantially modifiable?…[crickets]
Show of hands…who thinks the overall environment of healthcare is substantially modifiable?…[crickets]
Show of hands…who thinks the EHR interface is substantially modifiable?…[winner]
Yes, the EHR User Interface (UI) is the only realistically modifiable element in Freidman’s theorem and therefore our only salvation. This is important to understand because when it comes to fixing the EHR experience for clinicians we can stop complaining about the billing and coding requirements and stop lamenting all of the “quality” insertions, need for defensive medicine, and special “requests” coming from all directions. Like it or not, we simply need to accept everything that is being thrown at us clinicians (what choice do we really have?).
Let’s just require that it all be wrapped up and displayed (or hidden) in a clean, usable, dare I say elegant, interface. This will require smart content reduction and filters on almost every page of our current EHR experience. Non-clinical actions and requirements will need to be better automated to reduce the amount of digital garbage currently found throughout the electronic medical record.
A fresh clinical face to the EHR interface will not have any significant ROI in the short-term, so we need our business leaders to take the long view with appropriate value placed on clinician satisfaction and retention. We can do this, we just need to make (and fund) the EHR interface as an end-goal in and of itself.
So, here’s a call to all artists, aestheticians, interior designers, architects, ergonomic experts, and the like. All you people out there who make life beautiful. Your doctor will see you now.