Implementing electronic medical records (EMR) have been elevated to a top priority by healthcare policymakers. Using EMR, medical providers may be able to improve quality and better detect adverse events.
One way to improve quality with EMR is chart abstraction. After a physician-patient encounter, the doctor can review the medical chart to see if he or she prescribed the correct treatments or advice to the patient. This quality improvement methodology is certainly feasible without EMR, but is made much easier and inexpensive when patient records are held electronically. A paper by Luck et al. (2000) claims that chart abstraction may not capture all quality measures. In fact, chart abstraction typically underestimates the quality of care provided. This is likely due to the fact that physicians do not write down every minute detail of the visit and thus quality may be underestimated. Another issue is recording bias. “Busier practitioners may do more than they write down or good recorders may not be careful history takers (or physical examiners).” Plus, one must realize that a patients medical record serves multiple purposes. It is not only a medical document, but a legal record and a source of billing information. These facts may compromise the integrity of the EMR (e.g.: DRG creep).
A paper by Bates et al. (JAMIA 2003) claims that chart review or chart abstraction is overall a good technique, but may be too expensive for routine use and may fail to detect may adverse events. The Bates paper reviews a number of studies looking at electronic tools such as “event monitoring” and “natural language processing” which can help to detect problems before they occur.
EMR are only useful if physicians actually use them. A study by Miller and Sim (Health Affairs 2004) find that “the path to quality improvement and financial benefits lies in getting the greatest number of physicians to use the EMR (and not paper) for as many of their daily activities as possible. The key obstacle in this path to quality is the extra time it takes physicians to learn to use the EMR effectively for their daily tasks.” EMRs are only useful if all relevant data are included in the EMR. If most information is documented, but a physician records a patient’s allergies in the paper, but not electronic chart, there could be serious adverse medical affects. The Miller and Sim paper also proposes some solutions of how to best implement EMR.
Another unforeseen side-effect of using EMR that physicians will spend more time typing and gazing at a computer screen and less time interacting with the patient. A study by Margalit et al. (2006) finds that in Israel, “physicians spent close to one-quarter of visit time gazing at the computer screen.” The computer may enhance record keeping, but it also may diminish dialogue.
Finally, whenever EMR are implemented, they must be integrated in to the current systems in use. The new EMR must be integrated with the technology currently in use and well as the social system in place. One must also take into account the technical and physical infrastructure in place. For instance, Harrison, Koppel and Bar-Lev (JAMIA 2007) document that implementing computerized physician order entry at one children’s hospital “reduced beside nurse-physician interaction about critically ill infants. Nurses had fewer opportunities to provide feedback that sometimes led to beneficial medication changes.
- David W. Bates, MD, MSc, R. Scott Evans, MS, PhD, Harvey Murff, MD, Peter D. Stetson, MD, Lisa Pizziferri and George Hripcsak, MD. 2003. “Detecting Adverse Events Using Information Technology” JAMIA. 10:115-128.
- Harrison HI, Koppel R, Bar-Lev S. 2007. “Unintended Consequences of Information Technologies in Health Care–An Interactive Sociotechnical Analysis” J Am Medical Informatics Assoc. 14(5): 542-549.
- Jeff Luck, John W. Peabody, Timothy R. Dresselhaus, Martin Lee and Peter Glassman. 2000. “How well does chart abstraction measure quality? A prospective comparison of standardized patients with the medical record” The American Journal of Medicine. 108(8): 642-649.
- Margalit RS, Roter D, Dunevant MA, Larson S, Reis S. 2006. “Electronic medical record use and physician-patient communication: an observational study of Israeli primary care encounters.” Patient Educ Couns. 61(1):134-41.
- Miller RH, Sim I. 2004. “Physicians’ Use of Electronic Medical Records: Barriers and Solutions” Health Affairs. 23(2): 116-126.