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We’re a Bunch of Expensive Financial Clerks (04:16)

What might the next-generation electronic medical record (EMR) look like?

Eighty percent of an EMR’s functionality is commodities — maybe more, says Brent James, Vice President and Chief Quality Officer for Intermountain Healthcare. “We call it a services-oriented architecture, where you have patient identification, an electronic master patient index, you have security features, you have data persistence or data storage, you have order processing,” he explains. “The idea is to build a layer on top that can call those services, but that layer is completely under control of clinical teams, where you can define your own work environment.”

James describes an experimental next-generation electronic medical record at Intermountain that uses activity-based design. It ties directly to the organization’s shared baseline protocols, or care process models. “We were looking for the ideal system to support clinical decision support,” he says. “It gives a nice granular content to your data. It’s clinically natural — it’s the way you think about it, the way we think about it as doctors. And you can define it, change it. But it gave so much structure to the clinical environment that natural language processing began to work.”

Like an electronic clinical scribe, a doctor can talk about what he or she is doing, and the computer system captures it and coverts it into automatable computable data. “Most of what we capture today in electronic medical records is text, and that’s not computable,” says James. “If you can automate parts of this, it makes your life easier along the way.” It automates granular activity-based costing, and you can build coding systems into the semantic structure of the clinical record.

“One of my colleagues said, ‘Brent, you haul in these enthusiasts, these physician enthusiasts who wax on and on about this thing.’ I said, ‘You’ve got to understand. Give me any room full of physicians or nurses, give me about 20 minutes, and I’ll have a room full of enthusiasm. Because it fits the way that we think about our work.’”

“Epic is dead, Cerner is dead, in their current form. It’s only a matter of time,” James says. The original intent of EMRs was not financial, yet the current iteration is used to generate maximal fee-for-service billing, and that’s the reason physicians spend 2 hours at a computer for every hour they spend with patients, according to James. “We’re a bunch of very expensive financial clerks. What if you designed the system for physicians?”

James points to other examples of next-generation EMRs as well. “When you see those, you realize you’re seeing our future, and it’s a great future. And it can’t come soon enough.”

From the NEJM Catalyst event Physicians Leading | Leading Physicians at Intermountain Healthcare, July 12, 2017.

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