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Electronic Medical Records in the Gemba

The U.S. legislative and technology trends in healthcare systems have seen a move towards electronic medical records (EMR) as a way to improving outcomes and costs. The logic includes the portability of patient health history to any medical facility as well as reducing costs associated with manual records storage and retrieval. This week, however, I have had two experiences where new EMR systems have worked against both costs and outcomes.

IT's poor understanding of clinical gemba = Bad EMR design = More inefficiency and risk to patients

image - prescription writingThe first experience was where the manual prescription writing pad has been replaced by electronic prescriptions being sent directly to the pharmacy to be filled. It took two doctors and two assistants nearly ten minutes to enter the pharmacy data, and then only after the patient himself used his mobile phone to call the pharmacist to request the information.

The EMR system also did not return a confirmation screen to the physician, so everyone in the room was left uncertain whether the prescription had been sent or not. The patient had to call the pharmacist again to make sure it was indeed received and the medicine was in stock.

This reminded me of another experience a few months ago when the hospital was still using both written and electronic prescriptions. The dosage on the electronic prescription was four times the dosage on the hand-written prescription. Had I not had the written one to compare, I would not have caught the potentially dangerous error.

What EMR design misses could degrade healthcare quality rather than improve it

image - doctors using EMR

The second experience this week occurred when I related the first experience to the receptionist at a second doctor's office and then to the doctor himself. They both acknowledged two problems with the EMR:

Problem #1 was that the user interface with the software was so cumbersome that it was adding on average seven minutes to each patient visit. For example, a laboratory test request that used to be easy for doctors to fill out by hand by checking boxes on a form, now required that each test not only be entered manually but that each test also be linked to a diagnosis code. And, this had to be done for each lab test, one by one, and copying previously entered data was not allowed.

Even the screen displays reminded the physician of Windows 3 (1990) and had none of the usability one has come to expect in smartphone and tablet operating systems of the last five years.

Problem #2 was the most egregious. In both experiences this week, the doctors had to turn their backs to the patients in order to use the computer. One physician said that the ten minutes facing the computer screen would have been far better spent facing the patient as body language is a critical part of the interview and diagnosis procedure.

The other physician described the computer as"an unwanted 'third party' in the examination room interfering with the doctor-patient relationship." Wow! What a condemnation of what is expected to be one of the best innovations in healthcare.

Use Modern QFD tools to study clinical gemba and uncover unspoken VOC

The QFD connection here is the gemba research early in the Voice of Customer acquisition process. In the old days, practitioners of traditional QFD relied on customers to articulate their needs accurately and completely through questionnaires, surveys, focus groups, etc.

Students of Modern QFD now have a tool set that allows them to investigate unspoken VOC and customer needs by "going to the gemba." Gemba is a Japanese word often used in the quality movement to describe our factory floor where our products are made. It is at this gemba that our engineers can see improvement opportunities to increase production throughput, reduce quality problems, and improve safety. Great stuff.

But in QFD, where the focus is in new product development, factory operations (or their equivalents in service and software) do not yet exist. In such a case, the gemba shifts from our facility to our customer's.

In the case of the EMR software, for example, developers may have focused more on basic reporting functions than on physician usability and patient interaction. Since the gemba for using the EMR system is the doctor's examination room, investigation and analysis of the examination process would be vital to understanding user and patient needs, such as "I can observe my patient's reactions as I report my diagnosis and treatment recommendations," and "I can understand the trends in my condition."

Basic and advanced gemba tools and methods are now taught in the public QFD courses listed below.

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