First of its kind, lightweight and fast EMR, designed for Indian Doctors.
A subscription based model providing family doctors for urban India (Nationwide is a chain of clinics around different parts of the city (Bangalore-based startup) providing easy access to primary care.
NationWide was founded in April 2010 with a vision to become the most trusted and respected primary healthcare provider in India. Founded by UK-trained Indian doctors with several years of experience working in the National Health Service (NHS) in the UK in the field of family medicine.
Teamed with management experts they worked to develop a model that helped them create a ‘blue ocean’ – a strategy to create and capture an uncontested space.
The firm believes in a patient-centric model over a disease-centric model. The current problems in healthcare exist because the ‘whole’ patient is forgotten in the process of diagnosis and treatment.
The Nationwide Business Offerings :
My Role
My role was to design the EMR section of the business which is their main practicing tool for all the doctors and monitoring tool for the weekly operations. They (Nationwide) needed a fast, lightweight, and intelligent application to replace the traditional pen and paper documentation model which is cumbersome to store, process, analyze and share at scale.
This EMR was critical to their business success because manually it's difficult to document 1000s of patient health data on paper and track the operations of 20+ clinics around the city for years.
I proposed a cloud-based application which can be accessed via multiple devices like laptop and tablets (iPad etc) so that the home visiting doctors can easily record patient stats.
A unique lightweight EMR (Electronic medical record)
The purpose of the product is to solve a major use case of documenting patient records in a fast and reliable way.
In India, the number of patient visits for a GP doctor is a lot higher than in other developed countries and affordability also is a big challenge ( here in India, it costs around $5-$15 for a GP consultation.
In America, initial consultation with a doctor will cost in the range of $100 - $200. Visits to specialty care providers (specialists) are typically more expensive depending on their specialty and the nature of your visit. Specialists will charge $250 or more for a consultation.
The Indian healthcare system is not tightly coupled with Insurance, laws, etc and many patients need home visits thus the US-based enterprise-level EMRs which are designed as per their local environment cannot be very efficient and cost-effective in the Indian context so we had no option but to build a custom EMR from scratch for India and its healthcare practicing system.
What they were using earlier was just a simple form-based approach with tons of checkboxes and no intelligence built into their system which was a big-time waste for their top doctors.
I soon realized that they need an intelligent approach to documentation and we started working on the Information Architecture of this new product. We had a team of 4 doctors (from the nationwide side) for Inputs and review, 3 engineers from my team, 1 Project manager, and one designer (myself). Project Timeline: (2013-2014) around 11 months
Challenges
The biggest challenge here was to understand the domain deeply with all its users (doctors, nurses, patients, medical specialties, processes, protocols, legal issues, privacy, etc around the entire medical domain).
Doctors generally are not tech-savvy people but very fast with traditional practices like pen and paper, phone calls. Electronic record is an unusual idea for most senior doctors (45+), especially for it's learning curve and speed of inputs (doctors can't type as fast as they can write with a pen).
No one in our team had experience working with EMRs and the healthcare industry so the initial learning curve was very high. I used to question everything, why this way and not that way.
Doctors used to give their side of requirements in verbal format mostly because of their busy schedules, it took us some extra time to understand their terminologies and workflow requirements so perfecting a solution initially was tough without knowing all the use-cases.
Solution - Phase 1
Solving it with my design thinking process, i went with the following approach
Product definition (identifying the scope of work)
Research
Analysis
Design
Validation
In the beginning, I spent a lot of time understanding users and their real problems (requirements) and workflow on a daily basis so I used to sit with the practicing doctors at their clinic and understand what kind and scale of data processing they need on a daily basis and what is their exact expectation when it comes to a customized EMR.
I also checked other EMR products available in the market to understand what are the standard practices in the healthcare industry and do some competitive analysis of other EMR products.
Research Phase: Primary and Secondary
Primary Research
Understanding the basic components of an EMR like Diseases, Symptom types, Allergies, Processes, SOAP document, Lab Tests, Prescriptions, doses etc) and all its meta data to basically understand the data density and need of elasticity in the overall UX.
Secondary Research
Read books written by domain experts to understand the user psychology.
Also finding the standard practices in the EMR industry and what others follow at a globally.
Research Findings
After this research i found out that nationwide doctors need EMR primarily for the data entry part and sharing prescriptions with their clients on real time basis.
Nationwide mostly have chronic patients for illnesses like BP, sugar, asthma, obesity, heart conditions, etc which needs monthly/yearly tracking for managing the conditions under safety limits, and thus their vital data points need to be in a standard weekly report format.
Project Planning with Managers and Developers
Planning the priorities and feature releases as per the requirements (from Nationwide doctors) and technical ease of customizing/integrating features for the new EMR.
I commenced the work with SOAP, Doctor dashboard and Patient history. For the next 6 months, we did many iterative designs, tested them with doctors, did many changes, and finally arrived at this design which was a big success at the 1st phase of launch
The second stage was the IA (information architecture)
I asked the doctors to show me a lot of their patient diagnosis forms, Lab reports and other practice related documents so i can understand the size and nature of data before designing any screens.
some sample medical records that the doctors like to maintain before long term dosage prescription.
and some MRI and Xrays as well that doctors need to see frequently.
Information Architecture
After having many meetings with the doctors i realised that they need to capture the patient visit in the following standard format called SOAP
S= Subjective
O=Objective
A=Assessment
P=Plan
There is one more intro section they need to capture at the patient visit and that is CC ( Chief Complaint) which is basically the health issues as mentioned by the patient in her lingo.
We decided to develop the product in stages so our IA for the first stage was relatively simple
Sometimes I got such flow diagrams from the engineering PM as well so the data was coming from multiple sources after meetings, presentations and discussions on technical challenges.
Once the IA got approved by everyone in the team we started working on the screens for each workflow and refined the SOAP section with many critical contextual entries like:
Only for a female patient there should a column saying "Menstrual Periods Regular" = Yes/No
If a female is above 55+, that regularity of period question should not be there
If a person is diabetic, there should be a family history column for the same disease
We filtered medicines from the auto-complete list based on the allergic condition of the user so that doctor can not accidentally prescribe the wrong medicine
I tried to reduce the cognitive load as much as possible by making the forms shorter and let the system do intelligent form filling by implementing lots of standard auto-fills and smart suggestions built-in throughout the system. Doctors also liked this idea of auto-suggest and contextual form entries.
I started understanding the workflow of doctors and how they arrange patient data. Based on the documentation provided by the team i came up with the below structure which the Nationwide doctor (team of 8 doctors) appreciated a lot.
Solution - Phase 2 - ICD 10 dictionary integration
What is ICD-10
The ICD tenth revision (ICD-10) is a code system that contains codes for diseases, signs and symptoms, abnormal findings, circumstances and external causes of diseases or injury.
The need for ICD-10
Created in 1992, ICD-10 code system is the successor of the previous version (ICD-9) and addresses several concerns. ICD-10 codes are updated on a yearly basis, allowing addition, deletion and modification of existing codes. Annual revision of codes and code systems is primarily driven by research, the prevalence of new diseases, and insurance reimbursement needs.ICD-10 code system has been introduced to match the pace of the advanced healthcare and information technology industry.
How ICD-10 helps
ICD-10 contains more than 14,000 codes that can be sub-classified into 16,000 codes, catering to many new diagnoses. However, there are two main classifications used worldwide:
ICD-10-CM (Clinical Modification) – Diagnostic codes
ICD-10-PCS (Procedure Coding System) – Procedure Codes (for inpatients)
ICD-10-CM and ICD-10-PCS accommodate new procedures as well as new technology. Not only do these codes cater to a number of diagnoses, they also have the potential to provide better and updated data for improving overall patient and health care. The data obtained from the codes provides better understanding of complex disease conditions and allows designing of clinical algorithms to track patient care outcomes.
What an ICD-10 code looks like
ICD-10-CM Diagnoses Codes are 3-7 character codes. Character 1 is alphabetic, character 2 is numeric and characters 3–7 are alphabetic or numeric, with a decimal after 3rd digit.
ICD-10 Format (Click to expand)
ICD-10 Anatomy
Why we implemented the ICD-10 dictionary
Improved Quality in Clinical Documentation: The ICD-10 coding system is very much dependent on clinical documentation. Since thousands of diagnosis codes are added to ICD-10, the precision of the codes depend on clinical documents.
Greater Efficiency: By implementing ICD-10, a huge amount of data will be generated and can be mined for the betterment of public health.
Lesser Fraud: Adoption of ICD-10 will result in fewer fraudulent and exaggerated claims, which increases the cost of medical care and health insurance premiums.
Improved Healthcare Quality: ICD-10 coding setup supports a performance-based payment system.
Setting Health Policy: Since most of the world is using the ICD-10 code set, health officials can use the data to compare public health trends with global pandemics. This will help in setting up better health policies across the world.
Performance Monitoring: ICD-10 will improve a provider's ability to monitor services and resource utilization, analyze healthcare costs, monitor outcomes, and measure performance.
Accurate reporting: ICD-10 allows physicians to accurately report the complexity of the care provided and differentiate between chronic patients and those who come for routine check-ups.
Solution - Phase 3 - DICOM viewer integration
What is a DICOM viewer?
DICOM is the standard communications protocol used for capturing, storing, and transmitting medical images and related data. Phrased simply, DICOM in medical imaging acts as a blueprint for the information structures and procedures controlling the input and output of data in medical imaging systems. The term refers to both the protocol itself and its corresponding file format. All data obtained in the process of medical imaging is stored in this format. Without it, sharing information between different imaging devices would be significantly more difficult.
Benefits of using DICOM
Eliminating the need for physical storage – DICOM allowed imaging information systems to securely store medical images and data digitally.
Reduced costs and space requirements – Digital storage is significantly less expensive than the storage needed for hard-copy films. DICOM-compliant systems are far more cost-effective and provide a space advantage over the traditional film archives.
Better diagnosis and patient care – Access to information and diagnosis too were facilitated with the implementation of DICOM. The interoperability of DICOM-compliant devices ensures that medical data can be accessed by physicians worldwide. Telediagnosis, distance education, and accelerated peer review, consultation, and diagnosis are made possible. All of this provides a means for effective cooperation in the diagnostic process and better overall patient care.
Improved workflow – Manual filing, retrieval, and transport of folders are a thing of the past in medical imaging systems using DICOM. Faster image retrieval and the ability to access the images remotely allow physicians to work at a much quicker pace.
Easier access to patient data – DICOM-compliant systems offer more organized and convenient management of medical information. All patient data can be reached through a single point of access as images are integrated into the hospitals’ databases of DICOM images and related data.
Additional imaging services – DICOM provides many additional imaging services, including managing imaging procedure worklists, printing images on a film or digital media like DVDs, reporting procedure and archiving status, encrypting datasets, organizing layouts of images, encoding ECGs, CAD results, and structured measurement data, to list a few. DICOM-compliant imaging devices with diagnostic monitors enable clearer visualization of images in comparison to the traditional viewing of images on lightboxes.
Result
A lightweight Tablet friendly EMR.
After after a good 8 months of design and development effort we finally reached the first level of beta release which was good for all the UX enhancement demo that i was working on.
Doctors now could maintain and track 1000s of patient health records at the click of few buttons.
The overall efficiency of documentation and data quality improved significantly by going paperless, Transferring patient files became effortless .
Without carrying any bulky lab report prints, patients could just walkin for follow up visit and carry all their medical records in pocket.
Clinic level performance became easy to track and optimize for the hospital management (they could easily see which doctor is working at which clinic and how many patients have visited in a day at a particular clinic)
Before EMR
After EMR
Learnings and Takeaway
As a designer, it is very crucial to understand the business context, needs, and constraints to be able to create the right kind of design solution and get faster approvals from the top management. For example, is the business trying to get into a new market segment and looking to acquire new users? or the business is already established and needs to enhance its overall offerings to grow profits.
Simple and customized solutions have much higher satisfaction and adaptability (from the end-user) over complex and bulky enterprise-level solutions.
Understanding the problem and its components correctly is very important before jumping into the problem-solving mode.
Secondary research gave us ideas on medical industry standard practices.
Primary research showed us what problems need to be solved on priority.
Project management efficiency is a function of good documentation shared timely as a single source of truth with all the stakeholders.
A working prototype is more efficient and engaging than static screens for design demonstrations and idea testing.
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