Dr. Tom Lang (Enterprise Tracker) - EMR for the ER - the data entry gap

“I work in a couple different hospital emergency rooms. I trained in internal medicine, I worked as a critical care doctor, and I worked as a general internist for a large 40-doctor group for 10 years, as well as providing many physician management functions. Also, I did some administrative work for a year for a publicly traded company in physician management, so I’ve had a very broad background in medicine, mainly clinical, but I was always doing some business stuff along the way. I’ve now been an emergency room physician for about 10 years.”

So how, I asked, did EMR first come into the picture?

Dr. Lang explained, “I’ve never been a computer person at all, then about five years ago, a couple of the ERs I worked for started forcing the use of electronic records on the doctors in the ER. As I saw this happening, I got pretty discouraged about how doctors had to enter data in order to document their work tasks. I actually quit a favorite job of mine because of the problems associated with the lack of efficiency in using EMR in the ER.”

“Then I saw the tablet PC. I saw the potential for entering data in the ER. This is where I see the main problems with EMR—data entry with a mouse and keyboard doesn’t work—it’s too distracting and too time consuming. Working with Fritz Switzer [http://www.abletfactory.com/] over the past year and a half, I’ve been able to express my ideas to address what I see as the main problem with EMR—data entry for doctors.”

Forming a software development company called MACH 2 Solutions, principals
Fritz Switzer and Tom Lang, M.D. are both veterans with over 20 years apiece in their respective fields of software development and healthcare delivery.  They are both “nuts and bolts” men who enjoy solving everyday operational type problems by innovative means.  Together they have joined forces to tackle the following challenge: How do we integrate what we view as breakthrough technology of the Tablet PC into the everyday work flow of the practicing physician (as well as other healthcare workers)?

Fritz Switzer is an industry expert with 20+ years of Telecommunications, Software development and Management experience, and also, an active poster of the EMR Update Forum. (Just mention tablet PCs. He’ll be there.)  He has managed multiple projects and teams through all phases of life cycle development.  Fritz has a successful track record of identifying, motivating, developing and directing technology workgroups; Able to pinpoint and define organizational objectives as well as prioritize and schedule completion progression; Has been recognized as an industry expert in digital transmission and switching technology. 

Fritz founded and operates his own company devoted solely to creating software products for the Tablet PC.  His medical dictionary products are sold throughout the world in different languages.  A national speaker on development and implementation of Tablet rollouts and ROI, Fritz has achieved Microsoft MVP status for Tablet PC.

Is Dr. Lang saying that the tablet computer looked to him like a medical device?

“Essentially, yes. What I saw was that the workflow of scribbling a note on a scrap of paper WAS the learned, accepted, and practiced workflow for most doctors, and that “digital ink” as used on the tablet computer was the only thing which could match handwritten notes for speed and natural, reflexive workflow. The database technology of calling up patient data and examining that data for trends and insights is great. That part of the technology is right on the mark. But the stumbling block—inputting the documentation of the normal tasks of a doctor—just cannot be comfortably handled with a mouse and keyboard. Too slow. Too distracting.”

SYSTEM FEATURES of ENTERPRISE TRACKER
1. When used in its entirety, all workers within the hospital will perform all their tasks using a Tablet PC.
2. Modular design permits the benefits of incremental implementation.
3. Integration with existing “backbone IS” system can reinforce and enhance current IS investment.

PRODUCT MODULES
1. ER Tracker
2. CPOE Lite—includes both physician order writing and physician documentation.
3. Nursing documentation
4. Allied professional documentation

SYSTEM  BENEFITS
1. Extreme simplicity of design and matching of current workflows permits virtual overnight deployment without disruption of on-going operations.  Ability to reproduce your current forms in this new system is a huge step in this direction.
2. Healthcare worker can maximize time at the bedside.  Not only will this enhance worker and patient satisfaction, but this concept is an absolute cornerstone of patient safety and eliminates wasteful practices such as “double charting”.
3. Patient Safety: By delivering text drug orders to the pharmacy immediately from the “point of care” this system delivers the single most important pillar of patient safety.
4. All information about all patients in the system is no more than a pen tap or two away; not only is this of value to the “trench worker” but is obviously a valuable management tool as well.
5. Harnesses the incredible power of sharing all work and results immediately via the LAN.
6. Concurrent coding is now a reality by unlocking a previous “silo” of information: the daily progress note.  This is a valuable tool to optimize appropriate capture of co-morbidities and factors that can contribute to appropriate DRG documentation.
“Verbal orders” can be eliminated.  This is possible because a digital “order sheet” is always less than 2 seconds and no more than 2 pen taps away.

Never having used a tablet PC or digital ink myself, I asked Dr. Lang to tell me what he means when he says “digital ink”.

He replied, “It’s not like what you may have experienced using a PDA. It’s much more flowing in how you write because the screen is not actually pressure-sensitive. The pen you use is not just a stick-like stylus, it is an electronic device, a sensor. If you have never actually tried a tablet PC, go to a computer retailer and try it out.”

Are we talking about handwriting recognition for cursive writing, or do you have to separate each letter as you write?

Dr. Lang elaborated, “Yes, in fact it actually works better when you write in cursive, connected script. True handwriting. Fritz’s big invention is a dictionary of handwritten words which the system will recognize instantly.”

I had seen Fritz’s demonstration, and his handwriting is bloody awful. Yet the recognition of it by his system was perfect and instant. Was this some kind of trick?

“No,” according to Dr. Lang, “the secret ingredient is Fritz’s word recognition dictionary. Without the “competing interface” of the mouse and keyboard, it is possible to go at an incredible speed, because you don’t have to think about your documentation any more than you do with paper, yet you receive the great benefits of database technology which lets you retrieve and sort data after the fact.”

Instead of changing the doctor, you have just changed the writing surface? From paper to a tablet PC?

“Right,” answered Dr. Lang, “it boils down to workflow. I was spending too much time in front of the computer instead of talking to patients and nurses about the care of the patients. The key is to spend more time with the patient and the nurse, less time fighting my way through the EMR screens. Notice I say ‘fighting’ my way through. That’s bad for the patient, because it takes time away from talking with the patient and team-building with the nurse. I used to know where my nurses were going on vacation. That’s the hidden loss to the current methods of EMR data entry. The patients suffer a loss they probably don’t even understand.”

According to Dr. Lang, most of the features of most EMRs are not used by most doctors. He claims, “Until we can enter a world of pen-based data entry, we are not going to see major adoption of EMR by doctors. If you can make it simple enough, like a piece of paper, there is no reason to NOT take advantage of the advantage of the computer network in sharing medical information.”

What does Dr. Tom Lang wish to share about the future of EMR?

“The commercial products are not adequate. Most physicians do not find them satisfactory for their use. With updates and maintenance, where is the tech support going to come from in a small town? You need basic stuff that people can understand and not have to train to use it. There are some radical changes needed before doctors will totally accept electronic medical records. Right now, it’s not even close.”

Is Dr. Lang saying that EMR is not yet a commercially practical product?

He answered, “It’s not even close. Until we cross the barrier of doctors not being able to enter data, we are looking at early adopters who are using EMR at this time. The numbers I see are $10K for maintenance alone. Azyxxi [See this story: http://www.washingtonpost.com/wp-dyn/articles/A5780-2005Mar3.html] is a medical records system which is revolutionary in design. They’ve completely re-thought how EMR should work. No user manual—it’s obvious how to use it. That’s critical. The other thing is digital ink slash tablets. Tablet PC with digital ink plus the AZYXXI data retrieval system is what I see to be the winning EMR formula for the future.”

I was bold enough to ask if he and Fritz Switzer are working along those lines in their product design.

Dr. Lang’s answer: “You bet. Our Enterprise Tracker system is what we are working on together. Fritz's EMR toolkit wrapped around Office OneNote is his own product within his own company (the Ablet Factory) that I am helping him with a bit. If we are successful with Enterprise Tracker, we envision having the skills to build a complete RHIO (Regional Health Information Organization) using these building blocks and mixing them with some of the incredible technological tools that Fritz has introduced me to. Physician data input to computers is a "mission critical process that is broken" and I believe we can fix it.”

Dr. Lang added, “If I could state our mission, it might be: Let's take the best aspects of paper systems (catalyzed by digital ink technology) and the best aspects of computers and put them together in a way that will actually HELP physicians. Anything that takes the doctor away from the patient IS WRONG. The corollary here, "Documentation at the point of care" requires a truly mobile solution of the tablet, combined that other critical element that is so poorly understood: removing the mouse and keyboard from the equation to get rid of that ‘competing interface’, so that our product permits all tasks to be performed with only a pen interface.”

Never having used a tablet PC or digital ink myself, I asked Dr. Lang to tell me what he means when he says “digital ink”.

He replied, “It’s not like what you may have experienced using a PDA. It’s much more flowing in how you write because the screen is not actually pressure-sensitive. The pen you use is not just a stick-like stylus, it is an electronic device, a sensor. If you have never actually tried a tablet PC, go to a computer retailer and try it out.”

Are we talking about handwriting recognition for cursive writing, or do you have to separate each letter as you write?

Dr. Lang elaborated, “Yes, in fact it actually works better when you write in cursive, connected script. True handwriting. Fritz’s big invention is a dictionary of handwritten words which the system will recognize instantly.”

I had seen Fritz’s demonstration, and his handwriting is bloody awful. Yet the recognition of it by his system was perfect and instant. Was this some kind of trick?

“No,” according to Dr. Lang, “the secret ingredient is Fritz’s word recognition dictionary. Without the “competing interface” of the mouse and keyboard, it is possible to go at an incredible speed, because you don’t have to think about your documentation any more than you do with paper, yet you receive the great benefits of database technology which lets you retrieve and sort data after the fact.”

Instead of changing the doctor, you have just changed the writing surface? From paper to a tablet PC?

“Right,” answered Dr. Lang, “it boils down to workflow. I was spending too much time in front of the computer instead of talking to patients and nurses about the care of the patients. The key is to spend more time with the patient and the nurse, less time fighting my way through the EMR screens. Notice I say ‘fighting’ my way through. That’s bad for the patient, because it takes time away from talking with the patient and team-building with the nurse. I used to know where my nurses were going on vacation. That’s the hidden loss to the current methods of EMR data entry. The patients suffer a loss they probably don’t even understand.”

According to Dr. Lang, most of the features of most EMRs are not used by most doctors. He claims, “Until we can enter a world of pen-based data entry, we are not going to see major adoption of EMR by doctors. If you can make it simple enough, like a piece of paper, there is no reason to NOT take advantage of the advantage of the computer network in sharing medical information.”

What does Dr. Tom Lang wish to share about the future of EMR?

“The commercial products are not adequate. Most physicians do not find them satisfactory for their use. With updates and maintenance, where is the tech support going to come from in a small town? You need basic stuff that people can understand and not have to train to use it. There are some radical changes needed before doctors will totally accept electronic medical records. Right now, it’s not even close.”

Is Dr. Lang saying that EMR is not yet a commercially practical product?

He answered, “It’s not even close. Until we cross the barrier of doctors not being able to enter data, we are looking at early adopters who are using EMR at this time. The numbers I see are $10K for maintenance alone. Azyxxi [See this story: http://www.washingtonpost.com/wp-dyn/articles/A5780-2005Mar3.html] is a medical records system which is revolutionary in design. They’ve completely re-thought how EMR should work. No user manual—it’s obvious how to use it. That’s critical. The other thing is digital ink slash tablets. Tablet PC with digital ink plus the AZYXXI data retrieval system is what I see to be the winning EMR formula for the future.”

I was bold enough to ask if he and Fritz Switzer are working along those lines in their product design.

Dr. Lang’s answer: “You bet. Our Enterprise Tracker system is what we are working on together. Fritz's EMR toolkit wrapped around Office OneNote is his own product within his own company (the Ablet Factory) that I am helping him with a bit. If we are successful with Enterprise Tracker, we envision having the skills to build a complete RHIO (Regional Health Information Organization) using these building blocks and mixing them with some of the incredible technological tools that Fritz has introduced me to. Physician data input to computers is a "mission critical process that is broken" and I believe we can fix it.”

Dr. Lang added, “If I could state our mission, it might be: Let's take the best aspects of paper systems (catalyzed by digital ink technology) and the best aspects of computers and put them together in a way that will actually HELP physicians. Anything that takes the doctor away from the patient IS WRONG. The corollary here, "Documentation at the point of care" requires a truly mobile solution of the tablet, combined that other critical element that is so poorly understood: removing the mouse and keyboard from the equation to get rid of that ‘competing interface’, so that our product permits all tasks to be performed with only a pen interface.”

Dr. Tom Lang concluded with these thoughts: “Any system that takes longer than a few minutes to learn is unacceptable, and needs to be redesigned. This is the mantra of Dr Feied who is the designer of the Azyxxi system (focused on data extraction as opposed to our focus on data input). Drug orders need to be in text. This was our toughest nut to crack. Using what I call "Fritz's magic box technology", we can produce a drug order faster than I can scribble one. If it doesn't make you faster.....we don't do it.”

Is Dr. Lang interested in beta sites for the new EMR system?

He replied, “My biggest goal at the moment is finding a pilot site to roll out Enterprise Tracker.”