The Electronic Medical Record: Promises and Pitfalls

Jacob Reider, MD

In This Article

Where Is the "Real Problem"?

It may be intuitive that information retrieval is easier in electronic form than paper, yet until Paul Tang's work in 1994,[2] there was no evidence that a problem even existed with paper records. In Tang's study, researchers shadowed physicians in an outpatient setting and recorded the frequency with which the physicians could not find information in the medical record that they needed. In 81% of the clinical encounters, paper records were missing information that was needed at the time of the visit.

Have you ever been frustrated that you can't find the ECG from last November? How about the note from a referring physician that you know you saw 2 weeks ago before it went into the "filing pile"? These little frustrations can add up to increase the length of a visit, waste valuable physician and staff time, and distract the physician from the primary task of attending to patients. If we're missing something from 81% of our encounters, one can conclude that the paper system is not only inefficient and costly, but it is also unsafe.

While no standards body has yet defined paper records as unsafe, the enhanced safety[3] and enhanced compliance with health maintenance benchmarks[4] of electronic medical records are well documented.

Since the data for migrating to EMR are compelling, most physicians must be moving this way, right?

Wrong. While the estimates vary from 3% to 17%, there is compelling research that US physicians use electronic resources much less often than do their counterparts in Europe or Australia.[5] The report suggests that the differences in healthcare reimbursement account for the majority of barriers to more wide-scale EMR implementation in this country:

There is a simple explanation for these differences. In countries with national health services, or universal government-funded health insurance, there is a single payer (whether that is the federal or state, or provincial government). The single payer sets the rules. If the single payer says physicians must use electronic systems, they will do so. Furthermore, they can dictate a single nationwide system.[5]

While these data are interesting, the analysis oversimplifies the problem. A uniform reimbursement system may streamline billing issues, but EMRs in this country need to support the more complex documentation requirements in the United States. More important is that there has not been a coordinated national effort to identify the required components of an EMR or to provide adequate financial and administrative incentive for practices to take on the risks of implementing such systems.