Electronic Medical Records: A look at the past with a view into the future

By Dr. Paul G. Yungst, DPM, DABPS

Electronic Medical Records, called EMRs, are computer-based systems used for recording, delivering and managing patients' personal medical data. Computer-based patient records (CPRs) include any information taken at doctor visits, including medical history, physicals, Lab tests, prescriptions, referrals, and procedures performed in the office, hospital, clinics or outpatient offices. Lab information including biopsies, imaging, specimen tests, and diagnostic testing procedures are also listed in the record.

Dr. Lawrence L. Weed, known as the "father of the problem-oriented medical record (POMR)," first introduced the concept of the electronic medical record (EMR) in 1969. 28 years later in an article which appeared in the British Medical Journal in 1997 entitled "New connections between medical knowledge and patient care" Dr. Weed writes "medical practice requires tools to extend the mind's limited capacity to recall and process large numbers of relevant variables, just as medical science requires the microscope to extend our capacity to see at the microscopic level. We must abandon the arrogance of professional "expertise" that shuns such tools. Instead, we must use the new tools routinely as they are developed for more and more diagnostic and management problems." Why has it taken doctors so long to adopt Dr. Weed's insightful vision?

Methods of medical documentation have evolved in the past 50 years. In the early sixties the majority of doctors recorded patient care by hand writing notes in charts. With the development of the mini cassette in 1967 and the micro cassette in 1969, physicians and hospitals began adopting dictation/transcription which permitted more legible and thorough documentation of medical histories and examination findings. With the advent of digital computer technology we now enter the age of the EMR/EHR (electronic health record).

A short review of the history of the EMR should give the reader a better understanding of why medical documentation is moving in this direction. In 1968, Dr. G. Octo Barnett led a collaborative effort between the Massachusetts General Hospital Laboratory of Computer Science and the Harvard Community Health Plan to implement an automated medical record system. The Computer Stored Ambulatory Record (COSTAR) which they developed supported direct patient care, billing, and quality assurance programs like the monitored follow-up of treatment after positive throat cultures for streptococcus.

Another important and parallel step was the development of the Health Evaluation through Logical Processing (HELP) system. This integrated hospital information system, conceived in the late 1960s by a team led by Homer R. Warner, provided decision support for health professionals and demonstrated that computer systems could not only replace much of the paper record, but could also improve the process of care by enhancing the use of that record.

In 1991, the Institute of Medicine published The Computer-Based Patient Record: An Essential Technology for Health Care. This seminal document presented blueprints for the future of computer-based patient records (CPR). In the 1997 revised version, an expert committee explored the potential of CPRs to improve decisions about diagnosis and care, provided database for policymaking, and attempted to answer these questions: - Who uses patient records? - What technology is available and what further research is necessary to meet users' needs? - What should government, medical organizations, and others do to make the transition to CPRs?

In September 1999, the Quality of Health Care in America Committee of the Institute of Medicine (IOM) filed a report entitled "To Err is Human: Building a Safer Health System," In this report the Committee described a comprehensive strategy by which government, health care providers, industry, and consumers, could reduce preventable medical errors. One of the report's main conclusions is that errors are caused by faulty systems, processes, and conditions that not only fail to prevent mistakes, but often actually lead people to make them. In its subsequent report "Patient Safety: Achieving a New Standard of Care," dated November 2003, the IOM encouraged hospitals and physicians to adopt electronic medical records (EMRs) as a major step toward preventing medical errors.

In 2003 the RAND Health Information Technology (HIT) Project began a study of EMRs with two objectives: 1. To better understand the role and importance of EMRs in improving health care; 2. To encourage government actions that could maximize the benefits of EMRs and increase their use.
The RAND study estimated the potential savings, costs, and health and safety benefits of EMRs if it is assumed that interconnected and interoperable EMR systems are adopted widely and used effectively. Some of the key findings of their study included:
- Health Information Technology would save money and significantly improve healthcare quality.
- The annual savings from efficiency alone could exceed $77 billion.
- Health and safety benefits could double the savings while reducing illness and prolonging life.
- Obstacles to adoption of EMRs include market disincentives because in general, those who pay for Health Information Technology do not receive the related savings.

In response to these findings, the Federal government moved to improve health care quality, efficiency, and equity, and established the goal that nearly every American should have an EMR within ten years. But despite the involvement of federal agencies such as the Centers for Medicare & Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA), and the Agency for Healthcare Research and Quality (AHRQ), electronic systems have been adopted by only a small number of physicians and hospitals. In a study reported in the New England Journal of Medicine in 2008, DesRoches looked at the adoption of electronic medical records among 2,758 primary care physicians. Only 4% reported having an extensive, fully functional, electronic records system, and 13% reported having a basic system.

Private practices have been slow to adopt EMR because of early start-up costs and uncertain financial gains, according to a 2004 study by Miller and Sim. They noted that up-front costs for EMRs ranged from $16,000 to $36,000 per physician. During the initial weeks of using a new system, many practices also see fewer patients and spend more time entering data into their EMRs, which leads them to work longer days.

Another barrier to adoption is the current lack of data exchange among different EMRs and existing practice management systems. The typical office is deterred by the cost, complexities, and maintenance required in order to share data among different systems. Ideally, an office will buy a practice management system from the same vendor as their EMR, thus eliminating the need for a computer program that allows the two different systems to share data. Such sharing enables the office staff to use scheduling and registration data plus clinical data from the EMR to generate codes and charges automatically.

Data exchange is also an issue among EMRs and laboratory or radiology systems at area hospitals or testing centers. The necessary computer programs for such exchanges are either unavailable, or are costly to maintain and upgrade, with the result that paper reports must be scanned into the system. In order to track results over time, for reporting or for pay-for-performance purposes, staff must then manually enter those results into the EMR.

Despite these barriers there are numerous advantages to adoption of EMR in private practice. Predictions based on statistical models suggest that Health Information Technology has the potential to assist in dramatically transforming the delivery of health care, making it safer, more effective, and more efficient.

This has been my own personal experience. In 1997 after fifteen years of private practice in podiatry I transitioned from a dictation/transcription system to a basic electronic medical documentation system, MD Logic, Inc., a digital, touch screen, template driven system. Within the first year after the initial capital expense I began to realize a profit on my investment due to more accurate coding, added efficiency in office workflow, and increased referrals resulting from improved communications with referring physicians. The most significant effect was an increase in quality of care to my patients. Once the completed podiatric knowledge base was in place I was able to spend more time in face to face interaction with my patients and less time documenting. In 2006 I transitioned my group practice into MD Logic Worldwide EMR, a fully functional EMR, enabling our practice to go "paperless." All components of the patient's medical record are now stored on a hard drive and accessible from any computer at each of our offices. The streamlining of work flow and elimination of redundant tasks resulted in major improvement in the efficiency and attitudes of fellow employees. Instant access to patient's medical records and insurance information has proven to be an invaluable resource along with the creation of an interface permitting transfer of information from the medical record to the practice management billing software.

At this time the future direction of EMR appears to be in the hands of the government. The American Recovery and Reinvestment Act of 2009 provide significant cash incentives to physicians who implement electronic health records. However, in order to qualify for these incentives the physician must not only have the proper software but must engage in "meaningful use" of the software. The government has yet to define "meaningful use" thus making it impossible for EMR software vendors to guarantee incentive reimbursement to physicians. Additionally the Certification Commission for Health Information Technology (CCHIT), an independent non-profit organization recognized as the certification body for electronic health records, has yet to finalize the certification standards which will be required by the government.

Early adopters of EMR who have embraced Dr. Weed's vision have reaped numerous benefits of this innovative technology while preparing for health care delivery in the 21st century. Physicians now have a tool which can dramatically improve their medical outcomes and the quality of their patient's lives.