At the Department of Obstetrics and Gynecology at Penn State Milton S. Hershey Medical Center, patients and doctors now enjoy the benefits of a system which increasingly uses electronic medical records. But before the current EMR system was developed, administrators at Hershey had to learn a tough lesson – let doctors care for patients and allow technologists to figure out how to design software.

When the Obama administration in 2009 authorized billions of dollars in federal stimulus money to help hospitals and doctors with the costs of converting to electronic medical records systems, Dr John Repke embraced the promise of the new digital age. As Chairman of the Department of Obstetrics and Gynecology at Penn State Milton S. Hershey Medical Center and Professor of Ob/Gyn at Penn State College of Medicine, Repke’s challenge was to improve patient care and computerize mountains of paperwork.

His department employs 24 doctors, seven advanced-practice nurses and one physician’s assistant. It has five divisions: women’s health (general obstetrics and gynecology), maternal and fetal medicine (high-risk obstetrics), reproductive endocrinology and infertility, gynecological oncology and minimally invasive gynecologic surgery (including urogynecology).

Spread over four locations, Repke’s team conduct about 72,000 outpatient visits annually – everything from office visits for something simple like inserting an intrauterine device to more complex matters such as hysteroscopy surgery, endometrial and cervical biopsy procedures and loop electrosurgical excision procedures. They also perform more than 2,000 major gynecological surgeries annually and deliver more than 1,800 babies and have a busy robotics-surgery practice handling everything from infertility to cancer treatments.

The department is even part of reality TV folklore as the place Jon and Kate Gosselin had sextuplets in 2004 before becoming the focus of the TLC show “Jon & Kate + 8.”

CLEAR VISION

Repke and his faculty team had a clear vision for electronic records – to go beyond pieces of paper festooned with the often illegible scribbles of doctors and nurses. They wanted a comprehensive data repository to store all of a patient’s records from her medical history to her lab work and which could handle her many visits throughout a pregnancy. The system would bring records from prenatal care, out patient visits, the delivery and subsequent in-patient stay and records of perinatal care all into one place.

As well as making things like accessing records during off-hours and prescribing drugs easier, the new electronic system would also have secondary uses — doctors could harvest data for academic research, for quality reviews or to write reports and papers against.

“Physicians saw the power of these electronic records systems and started making them more and more complex, saying we can get this piece of information so let’s include that … because someday in the future we may want to do research on this and we will have all this information available,” Repke said in an interview about that ambitious 2009 effort to transition to EMR.
But, Repke now admits, that vision was fatally flawed at the outset.

Faculty wanted to use Cerner Corporation’s Millennium PowerChart software which the Hershey hospital system already used. But the software did not have the features they needed so faculty asked Hershey’s developers to build a new interface for it in house. Once built and deployed, the very thing that doctors had pushed for — a comprehensive system with myriad uses — was its undoing. It was simply too complicated, distracting doctors from their patients.

TOO MANY MICE CLICKS

“For a computer person if you are going to have to click a mouse six times to get to the field where you want to enter your information, it really does not seem like that big of an inconvenience,” Repke said. “But if you are a busy clinician who is seeing 20 or 22 patients in a half day, five days a week, 46 weeks out of the year, suddenly those clicks start to add up to real time and real annoyance.”

The doctors had designed the system they had wanted only to realize that they were not user interface or user experience experts. And, they realized, those skills were vital.

Hospitals and medical practices across America are rushing to put Electronic Medical Records systems in place to meet a 2015 deadline that demands they show meaningful use of such systems or face fines. Repke’s advice to those about to embark on electronic record projects is to start simple and build additional features later.

“We want to build computerized systems that are going to be simple, user friendly and reasonably comprehensive and accurate,” Repke said. “While that seems like it would be easy to do, it is not.”

“Our team got bogged down in trying to acquire so much information that it really became unusable,” He said. “We missed the initial mission, which was, ‘Let’s just duplicate electronically the current level that we have on paper and then … we can look at tweaking those systems and expanding them and trying to add other things.”

SOCIAL MEDICINE

As Vice Chair of the Department of Emergency Medicine and Chief Medical Information Officer at Penn State Hershey Medical Center, Dr Christopher DeFlitch must make sure that doctors and technology work well together. And as co-founder of the university’s Center for Integrated Healthcare Delivery Systems, he studies how technology affects the socialization of medicine, including how electronic records can alter interactions between doctors and patients.

DeFlitch said that Hershey’s Ob/Gyn department got better results when they took a different approach to building their electronic medical records system over the past couple of years. Rather than design the system themselves, the second effort saw faculty telling Cerner what they wanted from PowerChart. The doctors explained their workflows and what they wanted from the system and then let Cerner develop a usable interface.
“We took a step back and let Cerner work with some of its partners to develop a version of PowerChart that was better for us,” DeFlitch said.

The new effort paid off. The department is now almost fully on electronic records for gynecology. Obstetrics now uses a hybrid system with much of a patient’s information available electronically and some records still on paper. Cerner is scheduled to develop new features to complete the transition to electronic records within one to two years.

“The ease of the interface is significantly better than it was in the past,” DeFlitch said. “Getting it right took a combination of tool development by the vendor and a deeper understanding of the workflow need of the providers.”
“There are experts in each domain. Physicians and nurses are experts in providing care for patients and there are technical experts,” DeFlitch said. “The technology company cannot tell doctors how to take care of patients and the doctor cannot tell the technology company what to build. It is the partnership.”

Above all, DeFlitch said doctors must remember that what matters most is people.

“Medicine is a social game – people like to talk to other people, whether they are interacting with the record or not,” he said. “So in implementing EMR, if you think the computer is going to do something for you, you are wrong. The computer is just like a stethoscope or any other tool.”