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Evernote Is My EMR And Its Better Than The Rest

EvernoteEMRSpoiler alert: I’m not dying and there doesn’t appear to be anything major wrong with me.

I know, you hate spoilers. But I thought I’d get that one out of there way. It makes the rest of this considerably more pleasant for us both.

I’ve got a new personal electronic medical record. I’m able to store and track my health history. I can add and edit my own notes. I can pull in data from external sources like my quantified self gadgets. I can share data with my provider, or family members. It’s secure, it’s cloud-based, it’s mobile and it’s on all major platforms.

Evernote is my personal EMR.

For the uninitiated, Evernote is a cloud-based, free service with apps on every major desktop and mobile platform. It’s general purpose is to store, sort and help you find anything you throw at it. You can upload a PDF, email a note, clip an image from a website. You name it, and Evernote can probably store it. Take a picture of a wine label, and Evernote will transcribe the text in the image using optical character recognition, so when you search for Zinfendel, you’ll find the image of the wine bottle. But wait there’s more. Since you took the picture with your phone, Evernote also has the gps data, time and date attached to the image. You can add some tags such as “California”, “zin”, and “jammy” to make the note even more specic and personal.

Evernote has a widely supported API (applications programmers’ interface), so many other apps can read and write data into Evernote. For instance, the web-based automation service if this then that, IFTT as it’s known, will, for instance, append a line to an Evernote note every time you get a tweet; creating an effective backup solution.

I personally throw everything I can into Evernote. When I book travel, and the print window pops up over the itenary confirmation, it select PDF to evernote rather than print. When an online store emails me a receipt, I forward the email into Evernote. I have more IFTT rules logging things to Evernote than I can feasibly recount, but a few stand out. When I step on my Withings wifi-enabled scale, IFTT adds a line to an Evernote note with the date, time, my weight and body mass data. I can do the same thing with my Withings blood pressure cuff. And, it turns out, Evernote is pretty much perfect as a personal EMR.

In short, I get a lot of meaningful use out of Evernote.

Recently I was asked to get an MRI (see above re spoiler). I had the MRI done at a health system an hour away from my home. The system uses Epic and has the MyChart patient portal available. My primary care doctor also works for a system which uses Epic and has MyChart. But these two Epic installations might as well be separated by led walls. My PCP ordered some labs, that the other doctor needed and my PCP, in turn, wanted a copy of my MRI results. So one doctor calls me and says can you please print a fax to us the lab results. Mummmm, ok. It’s 2014 and I, the patient, am transmitting my own clinical data between two systems via analogue fax? Then my PCP wants a copy of the MRI results. Same problem. I am again reduced to data mule. I am Jacks health information edchange


So now we have two identical multi-million dollar EMR installations, each with some data about me, but neither having a complete picture or seamless interchange. Again, I’ll point out that this is 2014 and I can FaceTime someone around the world on my phone. And we’re using faxes?!?

But there is one place where I have a complete record of my health and health-related behavior. You guessed it, Evernote. Everytime I have a test done, I get an email from which ever isolated multi-million dollar Epic system at which I’m seen. I log in, and click a button on my web browser tool bar which instantly clips the entire page as both text and image and stores it in an Evernote notebook called Health.

The images from my MRI? They are in Evernote.

Last year, before my annual physical, I decided to eat my own dog food. I started a new note in my Health notebook called health observations. I captured the little things I wanted to remember throughout the year: an ache here, a reminder that I saw a physical therapist, a picture of the vitamin D supplement I started taking… Before my physical, I typed out an agenda in an Evernote note:

  • Review observations note
  • show picture of all supplements and capture into med reconciliation list
  • review journal article on psoriasis and glycerine and why I’m not using prescription steroids anymore
  • ask for opinions on nutritionalists

When I went into the physical, I let my physician do his HPI and med rec and then mentioned my agenda. He knows me well enough to find the humor in my proposal - hey, it’s pretty nerdy - but he graciously went along with it. He did his physical exam and then tuned control of the visit over to me. I asked if I could record the audio and did so using Evernote’s built in audio recording feature.

I also scan, or import PDFs of all my insurance data including EOBs (explanation of benefits). I scan medical receipts and co-pays. So I effective also have a rudimentary revenue cycle system.

I am nearly certain, today, Evernote has a more complete, more personalized view of my health and medical history than any other system on the planet. I can share entire notes, or their contents, via secure links to anyone I chose. I can automate data intake, or enter it manually. I can capture fitness and behavior data. I can trend, search, snapshot, and review my own medical records. I can add to them any time I want, from any device.

Please tell me why a multi-million dollar system is more patient-centered?

someone build this: put my tweets in my health record

There is a great deal of attention these days to the concept of electronic medical records (EMR). Sometimes we refer to them as electronic health records (EHR) or even personal health records (PHR). While there are semantic differences between each, the idea is the same: a complete, portable electronic snapshot of your health. At least that is the idea. In practice today we are really talking about an electronic record of your medical history. (notice I left out portable, complete and health). Enter the idea of accountable care. Many industry experts are already envisioning a near future when providers will move from reaction to proaction. Rather than being paid to treat the symptoms that walk in the door, doctors may get paid for keeping you out of the office. A practical example is obesity. Instead of being reimbursed to treat the side effects of obesity (asthma, diabetes, joint pain, etc), a doctor may get paid for helping a patient achieve a healthy lifestyle and losing weight.

There is still something missing from this equation. And that is where your social graph comes in. A lot of us do healthy things all the time. According to Foursquare, the geolocation based social network, I have "checked in" to my gym 57 times since early March. I have gone to the farmer's market 15 times this year. I have attended four medical education seminars (ok, those were work-related, but I still learned something). Here's the rub, my doctor doesn't know any of that. If he is going to be responsible for my complete health, shouldn't those things factor in?

So, continuing my "someone please build this" series of blog posts, here is my latest plea: someone please build a conduit between my social graph and my health record. Let me opt in and chose which things I share online which should also go into my EMR to become available for anyone treating me. Tools like Foursquare come to mind as an obvious choice. Since it is based on location, it takes some of the effort out of participating; it just knows where you are. So when I check in to the gym, wouldn't it be great if my health record was updated too?

My good friend and HCSM guru, Dana Lewis pointed out the power of twitter hashtags. What if we were able to define a specific, personal tag, say #NicksHealth. Every time I want to include a twitter update in my health record, I tag it with #NicksHealth. Last week, I had surgery on my knee to repair an ACL injury. Every day for the first week, I took a picture and loaded it into Flickr, the social photo sharing site and posted a link to the picture to Twitter. If I were able to tag it with #NicksHealth then my doctor would have a series of images showing the progression of my range of motion, wound healing, etc. When I update my Facebook page with details from physical therapy, that information could populate my medical record, along with my Foursquare checkins - my doctor would see just how compliant I have been with his rehab orders.

It doesn't all have to be healthy. Providers need a complete snapshot of our lifestyles if they are going to suggest a course of care. Perhaps through incentives, competition or other means, patients may be encouraged to also share things that are less healthy. "I ate a burger tonight, with fries…and bacon…lots of it. #NicksHealth" - My doctor should probably know how often that happens in relation to my trips to the gym.

There are, of course, some challenges to this idea; including the burden of combing through all the data. Physicians may already feel like they have information overload. Without an accountable care model in place today, there is not much to entice them to pour over patients' social graphs. In time, we will also need software that can automatically sift through the updates and present them in a meaningful way to physicians. However, the first step remains building the connection.

Every major social network has an API, or Application Programer's Interface. APIs are a way to move data into and out of systems. If you use a twitter client like Tweetdeck or Twitter on your iPhone, you are using the Twitter API. Health providers, when considering their online offerings, would be wise to build in API functionality to online health portals.

Let people chose which data they want to share with their medical record. Providers can incentivize participation through reduced co-pays, social competition, etc. In return they get a rich flow of lifestyle information. When accountable care, meaningful use, EMRs and social graphs come together it will be a win for us all.