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DOCtalk by Dr. Gregg 4/22/14

April 22, 2014 Dr. Gregg 7 Comments

Multiview: Prime Cut

Looking around at EMR/EHR options again – or, as always – one thing has begun to really stand out: the value of “multiview.” (In case you don’t know what “multiview” means, it refers to the ability of an EHR to allow the viewing of more than one function, and especially more than one function of more than one patient, at a time.)

OK , maybe the term “multiview” isn’t an industry standard, but I’d argue that it should be. After becoming comfortable with a system that easily allows viewing multiple components of a patient’s record at the same time, and one that also easily allows multiple views of multiple patient records at the same time, it has become virtually impossible for me to even consider any system that only allows a “one patient – one component” (OPOC) view.

OPOC seems comparable to the Buddha’s blind men describing an elephant by only experiencing one “view” of it.

4-22-2014 5-41-01 AM

Once you’ve become comfortable with multiple perspectives, with being able to see multiple “stories” at one time, with seeing interrelated parts and pieces, it becomes insufferable when you are only allowed to view the “one story, one element” window format of OPOC that seems to be the general industry standard in HIT.

The good part is that seeing what is available in EMR/EHR systems is becoming easier. More current EHR vendors are now offering “free” or “trial” versions that allow you to “try before you buy.” I love that. There’s no EHR demo, and certainly no EHR sales pitch, that can ever allow a provider to get as full a sense of what it’s like to work with a new EHR as a trial version can. Getting your hands on a system, even with a single “John Doe” test patient, provides so much more useful data on what it will be like to operate within the workflow of a new EHR. Kudos to those vendors who have figured out the value of the EHR test drive.

The hard part for me is looking at otherwise very intriguing systems who offer otherwise great functionality (and even otherwise wonderful pricing), but who are limited by the OPOC view.

Honestly, I don’t think it possible to go backwards. To even consider losing the ability to see multiple views within a patient’s chart at the same time, and especially to consider losing the ability to see multiple views within multiple patients’ charts at the same time, seems to have become a nonstarter. OPOC is a rate-limiting step, to be sure. I can’t seem to move past the consideration.

Even with a system that doesn’t offer all the specialty-specific features I’d prefer, even with a system that doesn’t provide 2014 MU certification (yet), even with a system that doesn’t have all the connectedness I’d prefer – all of this pales when compared to working with a system that allows me to see what I want, when I want, and as much as I want in the resizable, moveable window way with which I’ve so quickly become accustomed. Multiple views of multiple stories are multiply wonderful.

Multiview is one of the most dramatic ways that computerized documentation trumps paper records on a day-to-day-what-really helps-with-patient-care functionality basis. A paper chart requires flipping back and forth; OPOC systems do, too. Multiview allows a provider’s brain to do what it does best: easily view, consider, and synthesize multiple, disparate factors. Gray matter, at least the vast majority of non-eidetic-memory gray matter, isn’t very good at remembering all the little details; computers excel at this. But, gray matter beats the digital pants off of silicon for processing the bejesus out of data when given a multifactorial view. Gray matter can consider connections and nuances related to the human condition that escape even the most sophisticated electronic brains. (Watson, Tianhe-2, Mira, and their ilk may soon overtake us on this, but not just yet. Plus, gray matter is far more portable.)

4-22-2014 5-42-29 AM

Multiview has become my documentation standard of care. If you haven’t been fortunate enough to experience multiview in your EHR/EMR system, you’re probably better off. It’s hard to miss what you’ve never known.

For me, I’m now fully spoiled. Anything less than complete multi-manipulable, multi-scalableable, and multi-viewable has become multi-unacceptable. It’s like trying to pretend that chuck roast is fine, that I don’t know the exquisite texture and flavor of filet mignon.

But I do. Multiview is prime cut.

From the trenches…

“I’m very interested in structure, how multiple stories are assembled in different ways; that is what memory does as well.” – Nicole Krauss

dr gregg

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is Chief Medical Officer for Health Nuts Media, an HIT and marketing consultant, and sits on the board of directors of the Ohio Health Information Partnership (OHIP).

Comments 7
  • Never heard so much rambling about multiview or whatever in my life. Really
    Liked the “and no EHR sales person”. Line. Really tells us a lot.

  • This is one of those topics that tends to force out the “patient safety card.” Despite zero evidence on either side of the question, there are highly-placed people in many healthcare organizations who love to play that card when this topic is on the table. “Two patients open at once is an invitation to error,” they say. “Not on my watch,” they declare, confident that only bad things can happen when clinicians can see what they want. I get that it can be confusing to have lots of windows open, but given the work that we do, I am going to need some data to be convinced that it is a de facto safety problem. But that stance does not keep this card form being played.

  • How about a single clinical example of what you are describing, maybe even two? Make I’d pediatric specific, even. As so many physicians do when designing software, you’re doing the equivalent of saying “I just want a button here…” That’s how we end up w so many EHR Frankensteins (if you are using a top 10 ehr by user count, you know what I mean). Tell us what the problem is – you’ve done some of that here – and provide some good examples that affect you daily and then actually give the few UI experts a chance.

  • Re: Mr. Pragmatic

    Here’s an easy one: Checking a lab result for a blood culture, reviewing vitals and med history and ordering an antibiotic.

    As far as multiple patients: Take a look at your laptop. How many open browser tabs do you have open? How many apps? Is it more than one?

  • Hey, Anonymous, *I* can think of some examples myself too. I know what he’s getting at. But I don’t want to assume that I understand the problem, I want to hear it from the user. Maybe, for example, the EHR I work on does exactly what you are describing but in a different way (not “multiview”). Putting the solution before a great description of the problem (_what_ do you want to do and _WHY_) is how we get such crappy EHR UI now.

  • Hi Gregg,
    As you know, office-based physicians can now choose from a huge number of ONC-certified ambulatory EHRs.

    According to ONC’s Certified Health IT Product List ( http://oncchpl.force.com/ehrcert ), there are now a total of 4,279 ambulatory EHRs in compliance with Stage 1 and 2 Meaningful Use criteria. These include 1,931 for the 2011 Edition, 2,154 for the combination 2011 and 2014 Editions and 194 for the 2014 Edition. Few doctors shopping for an EHR solution are able to see more than several product demos, but even if it was possible to thoroughly test them all, I doubt any would have a user interface that embodies human-centered design principles.

    Have you seen more than one ambulatory EHR that allows viewing multiple components of a patient’s record at the same time and also offers “free” or “trial” versions that allow you to “try before you buy”?

  • I’m sure you can tell: I write mainly as a “storyteller.” (Thus, my “rambling” on my self-coined term of “multiview.”) I seek to tell tales that evoke an image or create an impression as compared to more detailed technical, problem-solution descriptives. I know that isn’t everyone’s cup of tea, especially on the technically-oriented pages of the HIStalk realm. However, “storified” opinion can sometimes evoke considerations and conversations beyond those enabled by strict technical writing.

    But, I’ll gladly provide some further details on the “here’s what I see and how it helps solve my workflow” issues (in a future post so I can be add sufficient details). My EMR is one on the few (only?) I’ve seen that has the “human-centered’ design stamp of approval from IDEO, http://www.ideo.com/, one of the stalwarts of such design thinking. I know that the value of user-centered design is not universally accepted, but it works for me. (And it’s far more than “I want a button here”!!)

    Plus, I’ll add a few thoughts on the patient safety issue the good Dr. Andy (Spooner) mentioned..

    (And, Bob, in my personal searches, I can’t think of more than one that does both. But, I’d sure learn to hear from other folks who may know of others that do so.)

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