Electronic medical records: Ask physicians what they want

When medical practices and hospitals don't get physicians involved in the planning, purchase and implementation of an EMR, this promising technology is doomed to fail.

Editorial. April 7, 2003.

For many physicians, it would be unthinkable to work without such nontherapeutic but essential technologies as pagers and cellular phones. Someday most physicians might feel the same way about electronic medical records.

But for now, those technologies represent a digital divide. It is often most pronounced between younger and older physicians, the tech-savvy and the tech-skeptical, and those apt to see the technology's upside while minimizing the downside versus those questioning that technology can acknowledge the seemingly infinite vagaries of the patient-doctor interaction.

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The EMR industry is still a nascent one, without technology standards, with products varying widely in price and quality, and with companies that aren't the household names that might bring skeptics some comfort. So until the perfect EMR arrives, installing a system will require not only computer knowledge but human engineering skills as well -- to bridge the "physician gap." Anyone installing a system, be it at a hospital or medical practice, must enlist -- and listen to -- the opinion of all physicians if this important technology can ever be expected to reach its potential.

That conclusion was borne out in a study published in the March/April Journal of the American Medical Informatics Assn. Studying the implementation of EMR at three hospitals, lead author Joan S. Ash, PhD, an associate professor of medical informatics at the School of Medicine at Oregon Health & Sciences University in Portland, found that all encountered physician resistance of some kind -- no surprises there. But the key to a successful implementation came when administrators listened to physicians' complaints and suggestions.

And why wouldn't anyone listen to physicians? After all, using an EMR demands a greater interaction between the physician and the medical record -- typing, note jotting (or talking for transcription), and formerly free-form chartwriters are often taken aback by the drop-down menus and stock phrases that are a common element of many EMR systems. There's a lot to learn -- and unlearn.

In exchange, the promise is a medical record -- when it works and the system doesn't crash -- that is always legible, never gets lost and can be accessed anywhere at any time. The EMR also holds the potential to make the users better doctors. Even now, some systems can flag drug interactions. There is also intriguing potential in the EMR's ability to gather information as well as hold it. For example, the Physician Consortium for Performance Improvement, an AMA convened-coalition of 60 experts from medical societies and other areas, is assisting physicians in using EMRs to track treatment patterns and determine if treatments meet quality measures developed by the consortium.

Despite this considerable upside, examples abound of EMR systems being pulled, or not working as intended. Often noted is that frontline physicians believe that they were shut out of the decision-making process for buying and implementing a system. Cedars-Sinai Medical Center in Los Angeles turned off the physician order-entry portion of its computerized system because physicians complained that entering and sending orders took longer -- even when they didn't get lost in the system. Cedars-Sinai said it consulted with a group of 40 physicians before implementing the system, but rank-and-file doctors said their voices were never heard. Consultants said that while that case was notable, there are more that never become public knowledge.

In our Feb. 17 issue, Commentary columnist Edmond Blum, MD, offered "Paperless medical record not all it's cracked up to be" on his serious misgivings about the EMR planned for the Brooklyn hospital where he practices as a general interest.

It received some Bronx cheers from pro-EMR physicians, writing in our letters-to-the-editor pages. But Dr. Blum and tech's early-adopters have more in common than they might realize. Both are against anything that might negatively affect quality of care or physician efficiency. If an EMR is going to have a positive effect, both the Dr. Blums and the tech advocates must be heard in making sure that happens.