A "skinny" EMR + your own custom tech stack

Back in the Sherpaa days of 2014 or so, we had Johns Hopkins (my alma mater) residents rotate through our virtual practice. The residents worked side by side with our doctors as they “project managed” our patients’ conditions. I sort of feel bad about what I’m going to say, but residents get the shaft sometimes right? But of course, only to advance science. So I had them time track our doctors and document what they were doing every minute of their day for a week. Again, I do feel bad. But! We learned a ridiculous amount from this exercise and we used this data to justify spending a year (!) integrating with Surescripts so our doctors could quickly and easily e-prescribe (this was before e-prescribing became a few weeks of integration work). We strategically built the features of Sherpaa's care team platform to sequentially tackle the biggest time sucks plaguing our doctors. Their time was expensive and if we could automate or streamline their repetitive tasks, it was an extremely worthwhile investment.

It’s interesting to think about what doctors do all day. For the most part, you can categorize their workflows into consuming content and creating content.

Consuming content involves:

• Talking/messaging with patients 

• Receiving lab and imaging results

• Receiving referral consults

• Receiving messages from your clinical team

• Researching clinical practices

• Researching who to loop in to care for your patients

• Viewing your schedule (if you operate in time slots)

Creating content involves:

• Prescribing medications

• Ordering labs

• Ordering imaging tests

• Making referrals to other docs

• Messaging with your clinical team

If your care model is quite consistent in terms of scope, complexity, business model, and where you deliver care, your technical needs are very predictable. You need a platform that helps your care team consume and create content specific to your care model. And across all care models, the atomic elements of care remain the same. So, your platform needs to excel at the most frequent time-consuming processes. Again, your most expensive line item is care team salary so you want to maximize their efficiency. 

The most common processes, in decreasing order of frequency, in modern care models are: 

• Patient onboarding

• Care team to patient messaging

• Care team-to-care team tasks and messaging

• Gathering a history and checking in over time

• Implementing standardized care plans

• Educating patients about their condition and plans 

• Prescribing medications

• Ordering labs

• Resulting labs

• Making referrals to external providers

• Receiving external provider consults

• Ordering imaging tests

• Resulting imaging tests

And, finally, there are features that are unique to modern care models that traditional EMRs simply either don’t have altogether or leave much to be desired. 

Things traditional EMRs can't handle:

• State-by-state workflows

• State-by-state user permissioning

• A single instance powering a nationwide medical group 

• A core architecture that’s not built around documenting scheduled in-person visits

• Online (especially asynchronous) as the primary communication channel

• Robust team-based collaboration tools

• Robust team-based online messaging

• Robust team-based task management

• Robust online patient education

• Online home fulfillment for meds, labs, or devices

• Events unique to a care model that trigger automated patient communications

• Standardized care plans with automated online action items for both patients and care teams that unfold over time

• Customized network of external specialists and facilities relevant to your geography and care model

• Payments (either transactional or subscriptions)

• Modern data architecture custom-built for insights and automations

• Robust data reporting unique to clinical operations and quality

So if you’re building a new care model, you don’t need all the 20th century bells and whistles. You need a “skinny” EMR and then a modern, customized, homegrown suite of features unique to your care model. 

The overlap between a “skinny” traditional EMR and your tech stack are:

• E-prescribing and medication management

• Lab ordering and resulting (if relevant)

• Imaging ordering and resulting (if relevant)

• Referral management (if relevant)

• Billing insurance or the government (if relevant)

• Scheduling (if you offer either in-person or online time slots)

Unfortunately, traditional EMRs aren’t even the gold standard of user experience for these core features. Everyone can agree they leave much to be desired. Traditional EMRs also literally don’t support mission critical features that modern care models require. These are things like state-by-state licensing, features available in one state but not available in another, and workflows required by one state but not by others. Also, most traditional EMR architecture was designed to support local physical clinics. If more clinics are necessary, that requires a separate instance of the EMR. If the team members at those clinics on separate instances want to collaborate or cover one another, they simply can’t. They were not, at their core, designed for nationwide medical groups on a single instance. That’s essentially a brand new concept for the US, unlocked by innovations in online care delivery. And the traditional EMR world can’t pivot due to their architecture. Also, the nationwide digital health single medical group concept is essentially just getting started. The market is not yet there for traditional players to even care about this new kind of potential customer.

Fortunately, these “core features” of a traditional EMR are now API integrations with companies like Dosespot, Health Gorilla, Zus, Ribbon Health, and many others. You can take advantage of the “unbundling” of 20th century EMRs that’s taken place over the last decade and be fully in charge of your own clinical care and operational metrics unique to your care model.