If God wanted us to type, She wouldn’t have given us transcription

Dictating is just faster than typing! Period!

If EMRs are to successfully roll out to all physicians, physician information entry has to be faster than dictating. Only the technologically eager (like me) or the coerced (like my partners who bought the product) will spend more time doing medical record-keeping than they did before EMR implementation. Those physicians who have a choice will still dictate.

Of course, medication and diagnosis lists are the exception, once they are established. But these elements can arguably be quite time-consuming.

Wise EMR products put a little "dictate here" icon at various points in the EMR to capture a voice file, for those times when a story must be told.

Dashboards from Sparklines: All Systems Go!

Dashboards will have several uses in the EMR environment.

• ICUs for displaying those 3-page wide flowsheets of clinical data: intake, output, vital signs, lab, drips, PCA.
• Chronic disease overviews: lab, home monitoring results, vital signs, prompts for next lab or immunization
• Quality Improvement: compliance with standards, progress toward targets, peer comparisons
• Pay for Performance: Budget, progress toward targets, return on investment
• Management dashboards: trends, year-to-year comparisons, key performance indicators

Here are some nice examples


Traffic light (colored dots of red) in the second column. Sparklines in the third column. Bullet graphs in the rightmost columns.



Microbar graphs on the lowest row, with sparklines just above them.


After you sketch out a new dashboard with pencil and paper, you may want to dress it up to show off before you start spending engineer time on it.

Here is a nice PowerPoint template for making high-fidelity wireframe mock-ups.


Download Dashboard Template

Sparklines: Coming to an EMR near you

Sparklines are data-intense, word-sized graphics designed to be incorporated into text. Used in an EMR, we can see the recent lab value and its associated trend over time.

Edward Tufte pioneered the concept of sparklines, and his website has a large collection of resources to those who want to explore sparklines further.

We should be using sparklines throughout our EMRs.

• As elements of clinical dashboards
• Monitoring chronic disease processes (lipids, A1C, renal function for diabetes)
• Monitoring vital sign and physiologic parameters in ICU patients
• Managing improvement trends in CQI processes
• Tracking financial performance in management dashboards

Where can I find code to implement sparklines?
Visit this site for links to non-commercial in several programming environments, including PHP, Javascript, C#, Lisp, Perl, Python, Ruby, Java, Excel VBA.

Commercial Implementations of sparklines include software add-ons for Excel:
Bissantz SparkMaker
MicroCharts
Business Refinery SimpleCharts

This graphic from MicroCharts gives detail on how we can show "normal range" or "target range" with a gray band, or a threshold value with a red line.



Developers! Start your engines!
Clinicians! All you need is pencil and paper to start sketching the dashboards, lab displays, and other graphs you need. Then share those with your EMR vendor.
Let's start seeing these word-sized, data intense graphics in all our EMR visual displays.

What are we aiming for?

In the world of making EMR's more helpful to clinician users, how high should we aim?

It's tempting for EMR vendors to try to impress with a long list of features. But that doesn't make me an Efficient user. It certainly doesn't sustain Enchantment after the sales demo, once I'm using the product.

I saw this nice illustration of the User Hierarchy of Needs at a blog called Creating Passionate Users.

I think we are around 2nd or 3rd stage for most EMR's. We might see pockets of Learnability or Efficiency in our own EMR. The most progress has been made in areas like managing medications and remembering diagnoses.

How would you rank your own EMR on the whole? Send your comments. Spread the word.