The other day, I saw my health care practitioner for a routine visit and noticed that the office had started using an electronic medical record (EMR). He came into the exam room with a small laptop computer, sat facing the computer, and entered information while asking me questions. At the conclusion of the visit, he handed me a computerized form that had both my prescriptions and laboratory orders.
As I came up the ranks in health care, the medical record (we always called it the “chart”) had been stored in a paper file in the physician’s office and contained various levels of information. The chart was a retrospective record of the encounter between clinician and patient. Over the years, government and regulatory agencies started dictating what the chart should contain. Attorneys now rely on the medical record as the legal documentation of what actually happened between clinician and patient.
Currently, there are snippets of medical information in records kept in various places where the patient has received treatment. A consistent effort to unify that information is lacking. The keeper of the record was always, of course, the physician. In recent years, we found that the physician and the patient actually “owned” the information and that both were entitled to control the access. Some say that the only way to create consistency of medical information is to move from the paper record to electronic storage and linkage: the EMR.
The strongest rationale for adopting the EMR is that it will allow all significant information to be accessible in one place. It can be organized, efficient, and searchable. Patient safety is another major justification. An EMR could inform the clinician about a patient’s allergy to a medication or an unfavorable interaction with another medication the patient is taking. Access to the complete medical record, whether in the clinic, the hospital, or any other health care setting, would save time, money—and certainly, lives. The biggest system using EMRs, the Department of Veterans Affairs (VA), has managed to improve every benchmark of quality in health care in the past decade. According to the VA, costs per patient were reduced 32% in the past decade, while the medical consumer price index has increased by 50%.
There must be some downside to this concept: Would the increasing longitudinal infor-mation—encompassing personal and family history, clinical encounters, laboratory and radiographic data, and referral material—result in data overload? The EMR should be capable of revealing complex trends and patterns. Who has the ability to create and/or alter an entry? Who will be keeping the record, and who owns it? What about retention? Whose responsibility is it to keep the records for the legally required amount of time? Aside from the obvious cost of EMRs, what about privacy and access? There must be both ethical and legal barriers. Recent well-publicized episodes of lost electronic health care data by the VA and the military illustrate that scrupulous ownership is imperative.
According to a report in the LA Times, about 150 people (from clinicians to technicians to billers) currently have access to at least part of a patient’s medical record during hospitalization, with more than 600,000 payers, providers, and others also having some access. If EMRs were instituted universally, would these numbers increase? Multiple access points may be a problem for protected health information and may cause HIPAA violations.
Do the benefits of EMRs outweigh the risks? If so, it may be clinically wrong to delay the development and implementation of EMRs in this country. Medical records are legal documents that must be kept unaltered and authenticated by the clinician or creator of the document. If we all agree that the patient owns the EMR and has the authority to grant privileges and access to the record, then the issues of privacy fall by the wayside.
During the presidential election campaign this past year, Barack Obama discussed extensive plans for investment in EMRs. In a postelection radio address he stated, “In addition to connecting our libraries and schools to the Internet, we must also ensure that our hospitals are connected to each other through the Internet. That is why the economic recovery plan I’m proposing will help modernize our health care system—and that won’t just save jobs, it will save lives. We will make sure that every doctor’s office and hospital in this country is using cutting edge technology and electronic medical records so that we can cut red tape, prevent medical mistakes, and help save billions of dollars each year” (see http://change.gov/newsroom/entry/the_key_parts_of_the_jobs_plan).
According to a 2008 survey conducted by the CDC, only 38.4% of physicians reported they were using full or partial EMR systems, and 20.4% said they were using minimally functioning EMRs for e-prescribing, ordering, and viewing results of lab tests. Only 17% of physicians reported using basic EMR systems. Clinicians are reluctant to use a system that does not mirror their practice style. Since programmers, who are not clinicians, develop most EMRs, the applications are not widely accepted.
What about hospital-based EMRs? A survey recently reported in the New England Journal of Medicine (2009;360:1628-1638) showed that only 1.5% of hospitals in the United States have a comprehensive electronic-records system. An additional 7.6% have a basic system. According to the study, larger hospitals and teaching hospitals were more likely to have electronic-records systems. Hospitals responding to this survey cited “capital requirements and high maintenance costs as the primary barriers to implementation.”
Based on what I hear from clinicians, the main reasons they are not readily adopting the EMR include: (1) it is too cumbersome and fosters depersonalization, (2) too much typing is required, (3) too many clicks are required for even minor tasks, (4) it is user-unfriendly, (5) it is too rigid—all notes look the same, (6) it is too time-consuming, and (7) it is too costly. One would think that EMRs should be built to conform to the individual practice style.
Although dictation remains one of the most efficient uses of a clinician’s time, a clinician may be drawn to utilize an EMR if there are offset benefits such as automated scheduling, ordering, billing, and prescription writing and integrated information systems. It appears that initial costs of an EMR system start around $71,000, with an annual cost of around $2,000. Unfortunately, we cannot simply go into an office supply mart and compare the features of various EMR products and choose the one that meets our need and is within our price range. There doesn’t seem to be uniform price structure to allow that kind of shopping.
Should we demand progress on implementation of user-friendly, cost-effective EMRs so that we can have access to a safer, more effective health care system, or is it all just “smoke and mirrors” and too much trouble? I welcome your comments about EMRs. Please send your responses to PAeditor@qhc.com.