CHOOSING AN
ELECTRONIC MEDICAL RECORD
Public Health & Policy
Prestigious groups,
such
as the Institute of
Physicians will need
Medicine (IOM), are
to be convinced that
asking physicians to
begin using an electronthe system will
ic medical record
improve the quality
(EMR). The IOM and
of care and not
other advocates suggest
that widespread adopsimply be a burden
tion of EMRs will
on their practice.
result in significant
improvements in quality of care and communication
among
physicians. Other reports emphasize cost savings from adopting an EMR system.1 The key question for individual physicians and physician groups is whether there is value in
converting from a paper system to one that relies on the electronic medical record.
The number of physicians following this advice is unclear,
since the percentage of physicians using EMRs varies considerably among studies. Geographic variation also exists in the
diffusion of the EMR system. Current reports indicate that
physician use of the EMR ranges from 10% to 30%.
“
”
IMPROVED QUALITY OF CARE
Major reasons groups such as the IOM are excited about
the EMR include its potential to improve quality of care
through prevention of medical errors, reduction of repeated
testing of patients, and improvement of the patient experience.
REDUCTION OF MEDICAL ERRORS
The impact of the electronic medical record on medical
errors in the private practice setting has not been discussed
widely in the medical literature, although the potential for significant improvement is vast. This is because few doctors in
ambulatory settings have implemented electronic medical
records, and the benefits are potentially most profound when
all doctors in a specific area participate. Since widespread
adoption has not taken place in many communities, it is difficult to precisely quantify the impact of the EMR in actual
Ankit Mahadevia is a medical student at Johns Hopkins University School
of Medicine, Baltimore, Md.
Dr Anderson is Professor of Health Policy and Management and Professor of
International Health, Bloomberg School of Public Health; and Professor of
Medicine, Johns Hopkins University School of Medicine, Baltimore, Md.
Advanced Studies in Medicine
by Ankit Mahadevia—Guest Columnist
Gerard Anderson, PhD—Column Editor
ambulatory settings. Instead, most of the analysis has relied on
expert panels. In 2003, for example, an expert panel estimated that implementation of an EMR would result in a
34% reduction in adverse drug reactions.2
More extensive studies have been completed on the
effect of the EMR in the inpatient setting. One evaluation
of the EMR in hospitals found that implementation of the
technology reduced medication errors by an average of 55%
and overall errors by 84% when compared to the control
group of hospitals.3 Another study of patients undergoing
orthopedic surgery found that physicians using the EMR
complied with clinical guidelines in 95% of cases as compared to 80% of physicians who used paper-based records.4
INCREASED CONTINUITY OF CARE
A recent survey of patient records from a large sample of
physician practices found that 81% of ambulatory records
lack at least 1 data element critical to the clinical encounter.5
Standardizing patient records by using the electronic medical record has the potential to reduce duplicative tests and
procedures, as clinical encounters are more likely to be
recorded properly and retrieved promptly.
Another future benefit is the possibility to create a unified
patient record by linking the records of multiple physicians.
This would help avoid the need to retake a patient’s medical
history and reduce the time to properly diagnose a patient
when records from a previous physician are unavailable.
IMPROVED PATIENT RELATIONSHIPS
Information technology can also improve the quality of
service provided to patients. The Mayo Clinic surveyed 478
primary care patients before and after the implementation
of an electronic practice management system and found
that 75% of patients found the software to have a positive
effect on quality of care.6
Many EMR systems are capable of alerting office staff
and patients of key health events, such as vaccinations,
follow-up visits, and appointments for screening tests. Such
features have been demonstrated to improve patient outcomes. In a review of 15 controlled trials in which diabetic
patients received computer-generated information, 12 of
the 15 trials documented positive clinical outcomes, such as
improved blood glucose levels.7 Other products make a portion of the medical record open to the patient, providing
the patient with a greater sense of efficacy and transparency
in the treatment process.
439
PUBLIC HEALTH & POLICY
THE COSTS OF CONVERSION
There are direct and indirect costs associated with conversion to an EMR system. Direct costs include the price of purchasing the software and hardware, training, implementation,
and ongoing maintenance and support of the electronic medical record. In general, this can range from $10 000 to
$20 000 for a 10-physician practice, with costs declining as the
size of the practice increases.4,8,9 The option of leasing rather
than purchasing technology can reduce acquisition costs. Apart
from maintenance and support, direct costs are a one-time
expense. As technology matures and a greater number of physicians purchase systems, these costs are likely to decline.
The direct costs are relatively small when compared to the
indirect costs. These are substantial costs involving the transition
from a paper to an electronic system. One major transitional
cost is a temporary decrease in physician productivity as a practice gains familiarity with the new records system. Although little rigorous data exist on productivity effects, a panel of experts
estimates that a 10-physician practice will require 3 months to
regain normal productivity, with 20% loss of productivity in the
first month after implementation, 10% in the second month,
and 5% in the third.4 In addition, documentation errors could
increase following the implementation and the abstraction of
historical charts into the electronic medical record. Indirect costs
will also vary based on the computer literacy of staff and physicians, the quality of support offered by the electronic medical
record vendor, and the size of the practice.
RECONCILING COSTS AND BENEFITS
A growing body of evidence suggests that the benefits of
electronic medical records outweigh the costs from a societal
perspective in the inpatient and outpatient settings. A study of
the EMR in the primary care setting found that its potential to
reduce medication utilization, radiology utilization, and billing
errors outweighed the cost of the technology by more than
$90 000 per physician for a 10-physician practice.4 An analysis
of several studies examining the EMR and adverse drug events
found that the majority of the time, avoidance of such events
alone outweighed the cost of the EMR.10 These studies may be
sufficient to encourage public and private insurers to pay for
doctors’ submissions of the electronic medical record, although
more studies will probably be needed. If all insurers were to pay
$5 for clinicians to complete an EMR for each ambulatory visit,
the cost would be approximately $10 billion per year.
A major challenge is making the benefits of the electronic medical record apparent to individual doctors.
Additional payments will help, but physicians will need to
be convinced that the system will improve the quality of
care and not simply be a burden on their practice. The
analysis is still developing.
MEDICAL ASSOCIATION INVOLVEMENT
Medical associations have taken steps to promote the
adoption of electronic medical records. The American
Academy of Family Physicians (AAFP) has been particularly
440
proactive in promoting electronic medical records, announcing a new initiative aimed at making an electronic medical
record system available to the solo practitioner.11 This system
would enable the creation of an EMR for a nominal cost,
maintain it in a secure Internet site, and share it with other
physicians and with the patient. No license would be required
for the software and the system would be able to run on existing equipment in the physician’s office. In addition, the
AAFP’s open-source electronic health record (EHR) pilot project is funding the implementation of the EMR at a limited
number of practices as part of a study on best practices in the
transition to a paperless office.12 Other associations, such as
the American College of Rheumatology, have compiled purchasing guides to assist physicians in the implementation of
the EMR.13 As the technology behind the EMR matures and
efforts to improve quality of care become more important, the
impetus for organizations to offer direct incentives for the
implementation of the EMR will continue to grow.
References
1. Committee on Quality of Health Care in America, Institute of
Medicine. Crossing the Quality Chasm: A New Health System for the 21st
Century. Washington, DC: National Academy Press; 2001.
2. Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician
order entry and a team intervention on prevention of serious medication
errors. JAMA. 1998;280(15):1311-1316.
3. Wang S, Blackford C, Middleton S, et al. A cost-benefit analysis of electronic medical records in primary care. Am J Med. 2003;114(5):397-403.
4. Durieux P, Nizard R, Ravaud P, Mounier N, Lepage E. A clinical
decision support system for prevention of venous thromboembolism:
effect on physician behavior. JAMA. 2000;283(21):2816-2821.
5. Tang PC, LaRosa MP, Newcomb C, Gorden SM. Measuring the effects
of reminders for outpatient influenza immunizations at the point of
clinical opportunity. J Am Med Inform Assoc. 1999;6(2):115-121.
6. Garrison GM, Bernard ME, Rasmussen NH. 21st-century health care:
the effect of computer use by physicians on patient satisfaction at a family medicine clinic. Fam Med. 2002;34(5):362-368.
7. Balas EA, Boren SA, Griffing G. Computerized management of diabetes: a synthesis of controlled trials. Proc AMIA Symp. 1998:295-298.
8. Health Information and Management Systems Society. Electronic
Medical Records: Why their time has come. Health Care Informatics
Industry Rep. January 2004.
9. Corley ST. Electronic prescribing: a review of costs and benefits. Top
Health Inf Manage. 2003;24(1):29-38.
10. Health Information and Management Systems Society. Electronic
Health Records and Return on Investments. Health Care Informatics
Industry Rep. March 2003.
11. Landrow L. Family doctors lead the pack, ready to embrace E-records.
Wall Street Journal. January 16, 2003.
12. American Academy of Family Physicians. Open EHR Project: Phase One.
Available at: http://www.aafp.org/x24963.xml. Accessed June 3, 2004.
13. American College of Rheumatology. Electronic Med Records for the
Physician’s Office. December 2003.
Enter your comments/suggestions at www.JHASIM.com
◆ Click on “Journal”
◆ Under 2004, click on “September”
◆ Under Columns
click on “Comments/Suggestions”
Vol. 4, No. 8
■
September 2004