Revelations From the Field: EMR Design Advice From a Clinician

Electronic medical records – you either love them or hate them. At least that’s been my observation. The more I write about EMR and talk to EMR developers and users, the more I notice there are two distinct camps regarding the technology. It’s a lot like Major League Baseball. You’re either a National League fan or an American League fan. It’s one or the other but never both.

alphaI totally understand how this happens. When EMR is implemented well, it can be very, very good. It can improve the delivery of healthcare by increasing data access and identifying trends in care and patient outcomes. But when it is bad, it’s very, very bad. Poorly designed and implemented EMR wastes time, causes redundancies and hinders provider communication. I know many of you in favor of EMR have a hard time believing that a faulty EMR system could be developed, launched, sold and rolled out to clients. Unfortunately, I have seen exactly that. I’m not going to name names, but why would a medication list not be alphabetized in a database? That’s a question – and not a theoretical one – I’d love to pose to a developer.

So based on some of my observations, I’d like to give some tips on things to consider when developing and implementing EMR.

Act like its paper

People like paper because it’s easy. You don’t have to scroll through menus, windows or drop-down boxes to find what you are looking for. You just open a chart and go to the vital sign flow sheet or find the progress note tab. Easy peasy. Information you need right away like vital signs and medication records are kept near a patient’s door for easy access. More in depth information like the list of physician orders or results from radiology are kept in a larger chart near the nurses station. This helps create a hierarchy of information and allows clinicians to find what they need quickly.When you are designing an EMR, I encourage you to think about presenting information according to this type of traditional hierarchy. Put the “I need it now” information at the front of the electronic chart. Don’t hide the vital signs in a tiny corner of the tenth screen of the fifteenth section of the workflow. Clinicians want and need this information in their face so put it where it can easily be found.

Keep up with the kids

I bet if you asked the most staunchly anti-EMR critic if they used Facebook or did some of their Christmas shopping online, they’d say yes. Why? Because Facebook and Amazon make it easy to use their sites. EMR should be the same way. It needs to be designed in a way that is intuitive and simple to use. For example, one program I have seen has a ‘cancel’ button at the top left corner of the screen. When a user makes a mistake and wants to go back a screen, instead of hitting a back arrow like most websites use, you have to go up to find a cancel button. Because I am so used to having back arrows or cancel buttons at the bottom right hand corner within a pop-up box, I constantly forget that this cancel button is an option.

By using navigation elements of some of the most used software, you’ll automatically make your EMR more user friendly.

Don’t do it just because you can

My endodontist uses an EMR that allows his staff to take a picture of each patient and attach it to his or her medical record. I’m assuming they do it to help prevent any medical errors that would be caused if patients had similar last names, for example, if there were two patients named Smith. It seems to work for them but I’ve also heard discussion about using cameras to document wounds. It could be helpful but only if the agency was committed to actually measuring progression or healing of wounds via EMR. If you are going to require staff to keep inputting lengthy wound assessment narratives, ask yourself why you are also requiring them to take pictures. There has to be intent to use the visual information you have your staff input rather than just taking a picture because you can.


I don’t like a lot of junk on my desk. My books, pens and magazines need to be organized rather than spread all over my work surface. An EMR program should be the same way. Compartmentalize sections the best you can using shaded areas to differentiate work areas. I prefer pop-ups or clearly labeled work areas rather than lots of scrolling through menus. For example, if I am charting on the endocrine system let me choose from two options –within normal limits or alteration in endocrine function. If I choose WNL, that should be it for charting in that section. I should not have to look through more boxes about a patient’s sliding scale insulin orders, which they wouldn’t have, or their glucose readings, which would be normal. Instead, just move me through the chart.

If I select altered function, then it’s ok to have boxes appear for me to enter data. But if everything is normal, I don’t want to see them on the screen. It makes it difficult to read and definitely wastes my time.

Show results

Clinicians want to know the reason for data entry. If they feel like they are entering information that will never be read or used in a meaningful way, then they’re not going to embrace your system. I’ve heard some EMR users say, “No one ever reads what we put in that section,” or, “Where does this information go? Who uses it?” Find a way to show them the fruits of their labor. Make it easy for them to read reports and trends. Charts and graphs help condense information into an easy to use format that can help drive future interventions and healthcare decisions.

I hope these suggestions help you bring out the very best that EMR has to offer, and I look forward to hearing some of your suggestions!

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Jennifer Thew, RN, MSJ

Jennifer Thew, RN, MSJ, is a registered nurse and journalist who has covered healthcare issues and how they relate to the nursing profession. She began her nursing career as a neuroscience nurse at Rush University Medical Center in Chicago and then transitioned to journalism after receiving a degree from Roosevelt University in Chicago. She has edited and written numerous articles on a wide range of nursing and healthcare topics like Accountable Care Organizations, evidence-based practice and telehealth.

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