Projects, designs, and writings on health IT

2015-02-22

Users want seamless, not necessarily same: The swiss army knife principle

8:51 AM Posted by David Do, MD , , No comments
My hospital underwent the transition to EPIC in the Emergency Room this week. We phased out a homegrown system, EMTRAC, which was developed in-house with plenty of input from the providers who used it. My immediate impressions were as follows:

The positive changes

  • Medications carry over automatically (there used to be a separate login)
  • Past medical history carries over automatically

The negative changes

  • There is so much superfluous information on the screen at the wrong time (Ebola screening, glascow coma scale when its not relevant, tetanus booster date, harm screen)
  • Content has been separated onto multiple different screens. The old system was fine tuned so you'd scroll from top to bottom to quickly get the story, from vitals, to labs, to medications, to prose. now they are paginated and you have to find the story.
  • The bed board is too small. It was previously big, clear, and projected on a large screen to quickly find open beds and locate patients
The swiss army knife principle: all-in-one is not always better. This image is courtesy of Amazon.com, where you can buy one of these.
A common complaint by providers in any institution is that there are "too many systems" and "too many logins". They want systems to "talk to each other", and they want all their interactions "to be on the same system". Off the top of my head, there are at least ten systems I use regularly that do a particular job in the hospital, a system with many moving parts.


  • Allscripts Sunrise EMR for inpatients
  • EPIC EMR for outpatients
  • EMTRAC emergency department EMR
  • Navicare for bed management
  • Cerner for labs
  • The radiology system
  • Penn image exchange for uploaded disc images
  • Pennrolodoc for consultant directory
  • Cureatr for secure text messaging

As our hospital transitions to a single system to control all tasks, a swiss army knife system, we lose the fine-tuning, the specialization, and we risk ending up with a single system that does none of the jobs as well. One clear example of this phenomenon happened when we replaced a number of systems related to residency scheduling, duty hour tracking, and procedure signoff with a single software package earlier this year.

Despite the words they use, what users are asking for is not for everything to be on the same system. They are, instead, asking for a seamless experience. How is this seamless experience possible with so many systems? We should be inspired by the companies that have solved integration problems in consumer web. Here are some of the apps and services I use in my personal life:


  • iPhone calendar and contacts
  • Google calendar and contacts
  • Facebook
  • Dropbox
  • Google documents
  • Evernote
  • RSS reader
  • Blogger

These services work together well enough to avoid the user feeling the redundancy. My calendars synchronize between multiple devices, I can access my friends' birthdays from Facebook in my calendar too. Last year I snapped hundreds of photos with my iPhone, which upload to my Dropbox, from where I curated them for an album of "Best of 2014". My mobile RSS reader compiles feeds from my favorite online publications so I can read them on the go. The keyword here is seamless experience, and its possible across an infinite number of systems. To make this possible, each of the software applications need to provide an application programming interfaces (API), and to ideally use some kind of standard health vocabulary. There is also work needed to integrate these products.

My hospital has taken several steps toward providing this seamless experience through its Medview application, which grabs data from multiple clinical information systems and acts as a hub that provides these data to a series of new apps that use these data. Providers can now use a handheld app to access data on a patient that includes lab data, vital signs, and notes. Soon we will have another app that alerts providers of new data in real-time. The benefits include but are not limited to a good user experience. Once this architecture is established, the number of apps can grow exponentially--and the more apps, the better. There is tremendous potential once we unleash the data to build apps for predictive analytics, population management, and novel research. The future of medicine is open data, and the institutions that move in that direction first will reap the rewards. 

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