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    The Electronic Medical Record: Promises and Problems

    William R. HershBiomedical Information Communication Center, Oregon Health Sciences University, BICC, 3 18 1 S. W. Sam JacksonPark Rd., Portland, OR 97201. Phone: 503-494-4563; Fax: 503-494-4551; E-mail: [email protected]

    Despite the growth of computer technology in medicine,most medical encounters are still documented on papermedical records. The electronic medical record has nu-merous documented benefits, yet its use is still sparse.This article describes the state of electronic medical re-cords, their advantage over existing paper records, theproblems impeding their implementation, and concernsover their security and confidentiality.

    As noted in the introduction to this issue, the provi-sion of medical care is an information-intensive activity.Yet in an era when most commercial transactions areautomated for reasons of efficiency and accuracy, it issomewhat ironic that most recording of medical eventsis still done on paper. Despite a wealth of evidence thatthe electronic medical record (EMR) can save time andcost as well as lead to improved clinical outcomes anddata security, most patient-related information is still re-corded manually. This article describes efforts to com-puterize the medical record.Purpose of the Medical Record

    The major goal of the medical record is to serve as arepository of the clinicians observations and analysis ofthe patient. Any clinicians recorded interactions with apatient usually begin with the history and physical exam-ination. The history typically contains the patients chiefcomplaint (i.e., chest pain, skin rash), history of thepresent illness (other pertinent symptoms related to thechief complaint), past medical history, social history,family history, and review of systems (other symptomsunrelated to the present illness). The physical examina-tion contains an inventory of physical findings, such asabdominal tenderness or an enlarged lymph node. Thehistory and physical are usually followed by an assess-ment which usually adheres to the problem-oriented ap-proach advocated by Weed ( 1969), with each problemanalyzed and given a plan for diagnosis and/or treat-ment. Subsequent records by the clinician are usually in

    G 1995 John Wiley & Sons. Inc.

    the form of progress notes, which are written for eachencounter with the patient, whether done daily in thehospital setting or intermittently as an outpatient. Inter-spersed among the records of one clinician are those ofother clinicians. such as consultants and covering col-leagues, as well as test results (i.e., laboratory or x-rayreports) and administrative data.These various components of the records are oftenmaintained in different locations. For example, each

    physicians private office is likely to contain its own re-cords of notes and test results ordered from that office.Likewise, all of a patients hospital records are likely tobe kept in a chart at the hospital(s) where care is ren-dered. Only at large health centers, where both hospitaland ambulatory care is provided (i.e., public or univer-sity hospitals), will the complete medical record for apatient exist in one location-and perhaps not eventhere.The medical record serves a number of otherpurposes. For example, it is used to provide documenta-tion that a patient was seen or a test was performed inorder that the clinician can obtain reimbursement by aninsurance company or government agency. It is also usedas a medium of communication among different clini-cians as well as ancillary professionals (i.e., nurses, phys-ical therapists, and respiratory therapists) who see thepatient. In addition, the medical record serves as a legalrecord in the event of claims due to malpractice or occu-pational injury. Finally, it also is used to abstract data formedical research.In recent years, the medical record has taken on new

    purposes. With the growing concern over the cost andquality of medical care, it serves as the basis for qualityassurance by health care organizations, insurance com-panies and other payors, and the federal government.This activity has taken on increasing importance withthe growth of managed care, which requires that clinicaldecisions be scientifically justified as well as cost-effective. Another more recent area of use has been indecision support, where clinicians are reminded aboutthe efficacy of or need for tests, or are warned about po-

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    tential drug interactions. All of these newer purposes aregreatly enhanced by the EMR.The Paper-Based Medical Record

    Despite the documented benefits of the EMR, mostclinical encounters are still recorded by hand in a paperrecord. This is not without reason. Dick and Steen( 199 1) note that the traditional paper record is still useddue to its familiarity to users, portability, ease of record-ing soft or subjective findings, and its browsabilityfor non-complex patients. There is also a sense of owner-ship of paper records, due to their being only one copy,which increases the sense of their security (although itwill be noted below that this may be a false sense ofsecurity).Nonetheless, there are many problems with paper-based medical records. The first is that the record canonly be used in one place at one time. This is a problemfor patients with complex medical problems, who in-teract with numerous specialists, nurses, physical thera-pists, etc. Another problem is that paper records can bevery disorganized. Not only can they be fragmentedacross different physician offices and hospitals, as notedabove, but the record at each location itself can often bedisorganized, with little overall summary. In most paperrecords, pages are added to the record as they are gener-ated chronologically, making the viewing of summarizeddata over time quite difficult.Another problem with the paper record is incomplete-ness. In an analysis of U.S. Army outpatient clinics, Tufoand Speidel ( 197 1) found as many as 20% of charts hadmissing information, such as laboratory data and radiol-ogy reports, a finding consistent with more recent obser-vations ( Korpman & Lincoln, 1988; Romm & Putnam,1981).A final problem with the paper-based record is secu-rity and confidentiality. Although usually ascribed as aproblem of the EMR, there are attributes of the paperrecord that increase its vulnerability to access by non-privileged outsiders. Its difficulty in duplication leads toa great deal of photocopying and faxing among providersand institutions. Furthermore, abstractions of the paperrecord are stored in large databases, such as those of theMedical Information Bureau, which are maintained byhealth insurance companies to prevent fraud but containmedical information of more than 12 million Americans( Rothfeder, 1992).Additional Challenges for the New Health Care Era

    The problems of the paper-based record listed aboveare magnified in this new era of health care fueled bymanaged care. Managed care systems, typified by healthmaintenance organizations ( HMOs), act as both healthcare insurer and provider. The traditional indemnity in-surer operates in a fee-for-service environment where the

    providers are reimbursed based on charges billed. Themanaged care organization, on the other hand, is pro-vided a fixed fee per patient, which gives it the incentiveto keep patients healthy and provide care cost-effectively. The benefits and drawbacks of managed careare beyond the scope of this article, but suffice it to saythat managed care will play an increasingly larger rolein the provision of American health care, and successfulmanaged care organizations require cost efficiency,which in turn requires effective management of informa-tion.There are many areas where improved informationmanagement can aid managed care organizations. Forexample, because many of these organizations providecomprehensive health care for their subscribers, theyneed effective communication between different provid-ers, ancillary staff, and/or hospitals. Likewise, they needto determine whether those groups are providing cost-effective care and not ordering excessive laboratory tests,x-rays, etc. Finally, these organizations often try to con-trol the use of expensive medications and substitute theiruse with cheaper but equally effective ones.Even outside the context of managed care, the effi-ciencies in communication and cost will be desired bysociety in general as the cost of health care continues toconsume larger proportions of the gross domestic prod-uct. All payors, even traditional fee-for-service insurancecompanies, are beginning to require it.Implementations of the Electronic Medical Record

    Although the complete EMR does not currently exist,portions of the medical record have been computerizedfor many years. The most heavily computerized aspectsare the administrative and financial portions. On theclinical side, the most common computerized functionhas been the reporting of laboratory results, usuallymade easier with the installation of automated equip-ment for laboratory specimen testing. As more informa-tion recording functions become computerized (i.e., cli-nician dictations transcribed into word processingsystems), i ncreasing proporti ons of the record are com-puterized as well.Dick and Steen note that all comprehensive EMRsshare several common traits ( Dick & Steen, 199 1). First,they all contain large data dictionaries that define theircontents. Second, all data are stamped wi th time anddate so that the record becomes a permanent chronolog-ical history of the patients care. Third, the systems havethe capability to display data in flexible ways, such asflowsheets and graphical views. Finally, they have aquery tool for research and other purposes.A number of successful EMR implementations havebeen in place for decades. One of the earliest ambulatorycare record systems was COSTAR (Computer-StoredAmbulatory Record), developed at Massachusetts Gemeral Hospital in Boston ( Barnett et al., 1979). It allows

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    patient registration and scheduling, storage and retrievalof clinical data, and financial capabilities such as billing.The core COSTAR system is in the public domain sothat other vendors and institutions can modify and en-hance it. Another well-known ambulatory system is theRegenstrief Medical Record System at Indiana Univer-sity (McDonald, Blevins, Tierney, & Martin, 1988)>which implements similar functions but is also well-known for its capacity for physician decision support(see below).There have also been a number of long-standing EMRsystems for hospitals. The HELP (Health Evaluationthrough Logical Processing) system was developed at theUniversity of Utah and Latter-Day Saints (LDS) Hospi-tal in Salt Lake City (Warner, Olmsted, & Rutherford,1972). Similar to the Regenstrief system, it attempts toactively assist physician decision-making by providingalerts of potentially problematic situations and remind-ers for routine care.Most of the above systems, as well as newer ones, haveevolved with computer and network technology itself.Most systems initially consisted of dumb terminals con-nected to mainframes or minicomputers, but have sinceevolved into microcomputer-based networks embracingclient-server architectures. Future technologies, such asvoice recognition or pen-based input, will likely causefurther evolution of these systems.Benefits of the Electronic Medical Record

    There are many potential benefits ofthe EMR. Unlikethe paper record, it can potentially be used by anyonewho needs it at any time. It can also be accessed easilyfrom remote sites. such as a clinic across town or evenacross the country. It is unlikely that data will be lost ormisplaced. With an appropriate back-up mechanism, itshould serve as a permanent record of an individualsinteraction with the health care system. Furthermore,with the availabili ty of all the patients data, new viewsand other summaries can be generated instantaneously.Finally, with the potential for the incorporat ion of re-minders and decision support, the likelihood of mistakesand omissions should decrease.In addition to benefiting the individual patient, theEMR is also likely to benefit the larger population. Clin-ical research will likely be enhanced, as researchers haveeasier access to information about patients that will in-crease understanding of disease and its treatment.Screening and other preventive measures will becomeeasier to implement as patients of various attributes (i.e.,gender, age, presence of other ri sk factors) can be identi-fied and contacted.A number of studies have documented some of thebenefits of the EMR. The most comprehensive work inthis area has come from Indiana University, where theRegenstrief computerized medical record system hasbeen developed over the last two decades. An initial clin-

    ical focus of the system was on reminders for cliniciansto perform various actions (such as ordering a test or pre-scribing as therapy) based on rules they had themselvesgenerated. Examples included the recommendation toorder a routine mammogram or check the serum potas-sium level of a patient on diuretic medication. A ran-domized controlled trial showed that physicians whowere given these reminders were more likely to complywith these measures that had been deemed important byphysicians themselves (McDonald, Hui, & Smith,1984).

    Most of the documented benefits of the EMR haveemerged from settings where clinicians use the systemhighly interactively as opposed to a passive replacementfor the paper record. This requires that clinicians use thesystem for order entry. where orders for tests and medi-cations are entered directly by the clinician. In anotherstudy at Indiana University, Tierney, Miller, Overhage,& McDonald ( 1993) performed a randomized con-trolled trial of a complete order entry system that in-cluded innovations such as displaying the cost of the testor medication. showing a list of pending tests, and di-rectly linking with an online drug reference manual.Those randomized to use the system were found to gen-erate 12.7% less charges without compromise in patientcare. Their patients also spent nearly one day less in thehospital. The authors estimated that implementing thissystem hospital-wide could save as much as $300,000.

    Another site of studies documenting the benefits ofthe EMR has been Brigham and Womens Hospital(BWH) in Boston. Cost savings in several areas havebeen documented due to display of less expensive butequally efficacious alternatives. For example, the medi-cation accounting for the largest cost of any single medi-cation in this hospital is the drug odansetron, used tocontrol nausea in cancer chemotherapy patients. By pro-gramming the order entry system to use as a default anequally effective but less costly dose, the hospital was ableto save $100,000 over a one-year period (Bates, Kuper-man. & Teich, 1994). The hospital is currently modify-ing its order entry system to remind physicians of testsordered too frequently, such as a serum theophyllinelevel ordered within 24 hours of a previous one (DavidW. Bates, personal communication).An additional measure to save costs has been the useof algorithms to assist decision-making. While compre-

    hensive expert systems such as QMR (Miller, Masarie,& Myers, 1986) are too time-consuming and complexfor everyday use, focused decision support has beenshown to be effective. At Brigham and Womens Hospi-tal, an algori thm to determine the probabilit y of chestpain being due to myocardial infarction (and hence as-sist with the decision to admit a patient to the hospital)has been shown to perform more accurately than physi-cians (Lee et al., 199 1). This allows patients most likelyto have myocardial infarction to be admitted to the in-

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    tensive care unit, with those less likely being admitted tothe regular hospital ward or being sent home.A problem with studies of EMR systems, however, isthat they tend to be site-specific (Dick & Steen, 199 1). Asuccessful EMR not only requires the proper technology,but also commitment from both health care institutionsand providers. Therefore, the same computer systemthat is very successful in one institution may fail misera-bly in another. As a result, studies of EMR systems canbe difficult to generalize from one institution to the next.Even within an institution, the EMR may be constantlychanging as technology and the software i tself evolve,making the results of a study of last years system lessmeaningful.Another problem in the assessment ofthe EMR is justwhat constitutes benefit. Being a highly quantitativefield, medicine is likely to require showing some numer-ical benefit, such as reduced cost or increased quantity orquality of life. It is difficult, however, to measure usersatisfaction for something as complex as the medical re-cord. Furthermore, given the complexity of factors thatimpact a patients outcome from an interaction with thehealth care system, it is difficult to isolate variables, suchas those related to the EMR, as the cause of beneficial oradverse outcomes ( Rind, Davis, & Safran. 1995 ) .Problems for the Electronic Medical Record

    A number of problems have been identified with theEMR, including increased provider time, computerdown time, lack of standards, and threats to confidenti-ality. Studies at the institutions described above (Bates,Kuperman, & Teich, 1994; Tierney et al., 1993) haveshown that electronic order entry increases the amountof time physicians spend entering orders. In the study atBWH (Bates, Boyle, & Teich, 1994), residents required44 more minutes per day using computerized order en-try, although internal medicine residents using the orderentry gained half of that time back in cost savings else-where. Furthermore. the overall rate of user satisfactionof the system was very high. Developing means tostreamline order entry are now a priority.Another concern with EMR systems is computerdown time. Although the threat of not having access tothe right piece of information at the right time is real, theincreasing reliability of computer systems makes this lessof a problem. At Oregon Health Sciences University, forexample, the daily scheduled down time has been re-duced over the last several years from 1 hour to 10 min-utes (Jim Elert, personal communication). Most hospi-tal computer systems and the databases that run on themare being designed for non-stop usage.A more significant problem with EMR systems is thelack of standards to interchange information. While anumber of standards exist to transmit pure data, suchas diagnosis codes, test results, and billing information,there is still no consensus in areas such as patient signs

    and symptoms, radiology and other test interpretation,and procedure codes. Although some associate the Na-tional Library of Medicines Unified Medical LanguageSystem (UMLS) with a comprehensive clinical vocabu-lary, its goal is much more modest, to serve just as ameta-thesaurus linking terms across different terminol-ogy systems (Lindberg, Humphreys, & McCray, 1993).A related problem to standards is that a large propor-tion of clinical information is locked in the form ofnarrative text ( Hripcsak et al., 1995 ). Although a num-ber of systems have been successful in limited domains(Sager. Friedman, & Lyman, 1987), the technology fornatural language processing (NLP) is still unable to in-terpret narrative text with the accuracy requ ired for re-search and patient care applications. While NLP isdifficult for well-written published medical documents,it is even harder for medical charts that contain poorlystructured, highly elliptical language, with frequent mis-spellings to boot. Even if such language could be parsed,the lack of an underlying framework make its semanticinterpretation more difficult (Evans, Cimino, Hersh,Huff, & Bell, 1994). Some have proposed to solve thisproblem with menu-driven data collection systems, butthese have generally been successful only in limited ar-eas, such as obstetric ultrasound (Bell & Greenes, 1994;Greenes, Barnett, Klein, Robbins, & Prior, 1970).A final concern about the EMR is the problem of se-curity and patient confidentiality. This problem, ofcourse, exists independent of the EMR, as a great dealof medical information. abstracted from paper records,already exists in electronic repositories. Well-known pri-vacy experts have documented the threats that misuseof this information has on personal privacy (Rothfeder,1992). As noted above, the paper record is no barrier toduplication, as medical records are routinely copied andfaxed among health care providers and insurance com-panies already. While some fear the EMR will exacerbatethis problem, others note that computer-based records,with appropriate security, are potentially more secureand at a minimum leave a trail of documentation ofthose who access them.Most medical centers already have security. Employ-ees given access are usually required to sign a confiden-tiality s tatement indicating their understandi ng of theprivacy of patient data. At most centers a password isrequired to enter the system, although some institutionsalso use a physical device, such as a key card. Virtuallyall systems also keep an audit trail of who accessed whichpatient and their data, providing a retrospective mecha-nism for discipline should breaches of security occur.While there currently exists an array of technologies,including encryption and authentication. that coulderect barriers between medical information and its un-authorized use, it must also be noted that there is a trade-off, as every computer user knows, between security andease-of-use. Since the pace of medical care in emergencysettings as well as busy clinical areas can be hectic, pro-

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    viders may become frustrated with layers of security. Aswith the information field in general. policies and legis-lation will need to be implemented that make the EMRusable but protect the individuals privacy.The Future of the Electronic Medical Record

    With the increased incentive to document and scruti-nize the delivery of medical care, the use of the EMRshould continue to increase. While this article has iden-tified many of its benefits, it has also listed some of thedrawbacks and impediments which need to be addressedfor the EMR to achieve i ts full potential.What are the challenges to developing the effectiveEMR? First, the system must be beneficial to the user,the individual clinician who will be entering the data andusing the results for patient care decisions. Thus, dataentry must not be excessively time-consuming or other-wise difficult, while obtaining information out must besimilarly fast and easy. Clinician involvement is crucialfor successful implementation of EMRs (Bria & Rydell,1992 ). On the other hand, the system must not compro-mise patient confidentiality. Reasonable mechanismsmust be implemented to insure patient information isnot viewed by inappropriate viewers and those whobreach security are appropriately punished. However,the security must not be so restrictive as to impede use ofthe system by clinicians.It is likely that the clinician of the future will interactheavily with computers. Not only will various processesof health care delivery become increasingly automated,but larger amounts of non-patient information, such asthe medical literature, will also be accessed electroni-cally. This future clinician will likely use a computer toenter findings and diagnoses, take advantage of links thatconnect these with decision support modules and themedical literature, and communicate with colleaguesand others taking care of the patient.ReferencesBarnett. G., Justice. N.. Somand. M., Adams, J.. Waxman. B., Beaman,

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