The Electronic Medical Record: Promises and Problems

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

Despite the growth of computer technology in medicine, the form of progress notes, which are written for each most medical encounters are still documented on paper encounter with the patient, whether done daily in the medical records. The electronic medical record has nu- hospital setting or intermittently as an outpatient. Inter- merous documented benefits, yet its use is still sparse. This article describes the state of electronic medical re- spersed among the records of one clinician are those of cords, their advantage over existing paper records, the other clinicians. such as consultants and covering col- problems impeding their implementation, and concerns leagues, as well as test results (i.e., laboratory or x-ray over their security and confidentiality. reports) and administrative data. These various components of the records are often As noted in the introduction to this issue, the provi- maintained in different locations. For example, each sion of medical care is an information-intensive activity. physician’s private office is likely to contain its own re- Yet in an era when most commercial transactions are cords of notes and test results ordered from that office. automated for reasons of efficiency and accuracy, it is Likewise, all of a patient’s hospital records are likely to somewhat ironic that most recording of medical events be kept in a chart at the hospital(s) where care is ren- is still done on paper. Despite a wealth of evidence that dered. Only at large health centers, where both hospital the electronic medical record (EMR) can save time and and ambulatory care is provided (i.e., public or univer- cost as well as lead to improved clinical outcomes and sity hospitals), will the complete medical record for a data security, most patient-related information is still re- patient exist in one location-and perhaps not even corded manually. This article describes efforts to com- there. puterize the medical record. The medical record serves a number of other purposes. For example, it is used to provide documenta- Purpose of the Medical Record tion that a patient was seen or a test was performed in order that the clinician can obtain reimbursement by an The major goal of the medical record is to serve as a insurance company or government agency. It is also used repository of the clinician’s observations and analysis of as a medium of communication among different clini- the patient. Any clinician’s recorded interactions with a cians as well as ancillary professionals (i.e., nurses, phys- patient usually begin with the history and physical exam- ical therapists, and respiratory therapists) who see the ination. The history typically contains the patient’s chief patient. In addition, the medical record serves as a legal complaint (i.e., chest pain, skin rash), history of the record in the event of claims due to malpractice or occu- present illness (other pertinent symptoms related to the pational injury. Finally, it also is used to abstract data for chief complaint), past medical history, social history, medical research. family history, and review of systems (other symptoms In recent years, the medical record has taken on new unrelated to the present illness). The physical examina- purposes. With the growing concern over the cost and tion contains an inventory of physical findings, such as quality of medical care, it serves as the basis for quality abdominal tenderness or an enlarged lymph node. The assurance by health care organizations, insurance com- history and physical are usually followed by an assess- panies and other payors, and the federal government. ment which usually adheres to the problem-oriented ap- This activity has taken on increasing importance with proach advocated by Weed ( 1969), with each problem the growth of managed care, which requires that clinical analyzed and given a plan for diagnosis and/or treat- ment. Subsequent records by the clinician are usually in decisions be scientifically justified as well as cost- effective. Another more recent area of use has been in decision support, where clinicians are reminded about G 1995 John Wiley & Sons. Inc. the efficacy of or need for tests, or are warned about po- tential drug interactions. All of these newer purposes are providers are reimbursed based on charges billed. The greatly enhanced by the EMR. managed care organization, on the other hand, is pro- vided a fixed fee per patient, which gives it the incentive to keep patients healthy and provide care cost- The Paper-Based Medical Record effectively. The benefits and drawbacks of managed care Despite the documented benefits of the EMR, most are beyond the scope of this article, but suffice it to say clinical encounters are still recorded by hand in a paper that managed care will play an increasingly larger role record. This is not without reason. Dick and Steen in the provision of American health care, and successful ( 199 1) note that the traditional paper record is still used managed care organizations require cost efficiency, due to its familiarity to users, portability, ease of record- which in turn requires effective management of informa- ing “soft” or “subjective” findings, and its browsability tion. for non-complex patients. There is also a sense of owner- There are many areas where improved information ship of paper records, due to their being only one copy, management can aid managed care organizations. For which increases the sense of their security (although it example, because many of these organizations provide will be noted below that this may be a false sense of comprehensive health care for their subscribers, they security). need effective communication between different provid- Nonetheless, there are many problems with paper- ers, ancillary staff, and/or hospitals. Likewise, they need based medical records. The first is that the record can to determine whether those groups are providing cost- only be used in one place at one time. This is a problem effective care and not ordering excessive laboratory tests, for patients with complex medical problems, who in- x-rays, etc. Finally, these organizations often try to con- teract with numerous specialists, nurses, physical thera- trol the use of expensive medications and substitute their pists, etc. Another problem is that paper records can be use with cheaper but equally effective ones. very disorganized. Not only can they be fragmented Even outside the context of managed care, the effi- across different physician offices and hospitals, as noted ciencies in communication and cost will be desired by above, but the record at each location itself can often be society in general as the cost of health care continues to disorganized, with little overall summary. In most paper consume larger proportions of the gross domestic prod- records, pages are added to the record as they are gener- uct. All payors, even traditional fee-for-service insurance ated chronologically, making the viewing of summarized companies, are beginning to require it. data over time quite difficult. Another problem with the paper record is incomplete- Implementations of the Electronic Medical Record ness. In an analysis of U.S. Army outpatient clinics, Tufo and Speidel ( 197 1) found as many as 20% of charts had Although the complete EMR does not currently exist, missing information, such as laboratory data and radiol- portions of the medical record have been computerized ogy reports, a finding consistent with more recent obser- for many years. The most heavily computerized aspects vations ( Korpman & Lincoln, 1988; Romm & Putnam, are the administrative and financial portions. On the 1981). clinical side, the most common computerized function A final problem with the paper-based record is secu- has been the reporting of laboratory results, usually rity and confidentiality. Although usually ascribed as a made easier with the installation of automated equip- problem of the EMR, there are attributes of the paper ment for laboratory specimen testing. As more informa- record that increase its vulnerability to access by non- tion recording functions become computerized (i.e., cli- privileged outsiders. Its difficulty in duplication leads to nician dictations transcribed into word processing a great deal of photocopying and faxing among providers systems), increasing proportions of the record are com- and institutions. Furthermore, abstractions of the paper puterized as well. record are stored in large databases, such as those of the Dick and Steen note that all comprehensive EMR’s Medical Information Bureau, which are maintained by share several common traits ( Dick & Steen, 199 1). First, health insurance companies to prevent fraud but contain they all contain large data dictionaries that define their medical information of more than 12 million Americans contents. Second, all data are stamped with time and ( Rothfeder, 1992). date so that the record becomes a permanent chronolog- ical history of the patient’s care. Third, the systems have the capability to display data in flexible ways, such as Additional Challenges for the New Health Care Era flowsheets and graphical views. Finally, they have a The problems of the paper-based record listed above query tool for research and other purposes. are magnified in this new era of health care fueled by A number of successful EMR implementations have managed care. Managed care systems, typified by health been in place for decades. One of the earliest ambulatory maintenance organizations ( HMO’s), act as both health care record systems was COSTAR (Computer-Stored care insurer and provider. The traditional indemnity in- Ambulatory Record), developed at Massachusetts Gem surer operates in a fee-for-service environment where the eral Hospital in Boston ( Barnett et al., 1979). It allows patient registration and scheduling, storage and retrieval ical focus of the system was on reminders for clinicians of clinical data, and financial capabilities such as billing. to perform various actions (such as ordering a test or pre- The core COSTAR system is in the public domain so scribing as therapy) based on rules they had themselves that other vendors and institutions can modify and en- generated. Examples included the recommendation to hance it. Another well-known ambulatory system is the order a routine mammogram or check the serum potas- Regenstrief Medical Record System at Indiana Univer- sium level of a patient on diuretic medication. A ran- sity (McDonald, Blevins, Tierney, & Martin, 1988)> domized controlled trial showed that physicians who which implements similar functions but is also well- were given these reminders were more likely to comply known for its capacity for physician decision support with these measures that had been deemed important by (see below). physicians themselves (McDonald, Hui, & Smith, There have also been a number of long-standing EMR 1984). systems for hospitals. The HELP (Health Evaluation Most of the documented benefits of the EMR have through Logical Processing) system was developed at the emerged from settings where clinicians use the system University of Utah and Latter-Day Saints (LDS) Hospi- highly interactively as opposed to a passive replacement tal in Salt Lake City (Warner, Olmsted, & Rutherford, for the paper record. This requires that clinicians use the 1972). Similar to the Regenstrief system, it attempts to system for order entry. where orders for tests and medi- actively assist physician decision-making by providing cations are entered directly by the clinician. In another alerts of potentially problematic situations and remind- study at Indiana University, Tierney, Miller, Overhage, ers for routine care. & McDonald ( 1993) performed a randomized con- Most of the above systems, as well as newer ones, have trolled trial of a complete order entry system that in- evolved with computer and network technology itself. cluded innovations such as displaying the cost of the test Most systems initially consisted of dumb terminals con- or medication. showing a list of pending tests, and di- nected to mainframes or minicomputers, but have since rectly linking with an online drug reference manual. evolved into microcomputer-based networks embracing Those randomized to use the system were found to gen- client-server architectures. Future technologies, such as erate 12.7% less charges without compromise in patient voice recognition or pen-based input, will likely cause care. Their patients also spent nearly one day less in the further evolution of these systems. hospital. The authors estimated that implementing this system hospital-wide could save as much as $300,000. Benefits of the Electronic Medical Record Another site of studies documenting the benefits of the EMR has been Brigham and Women’s Hospital There are many potential benefits ofthe EMR. Unlike (BWH) in Boston. Cost savings in several areas have the paper record, it can potentially be used by anyone been documented due to display of less expensive but who needs it at any time. It can also be accessed easily equally efficacious alternatives. For example, the medi- from remote sites. such as a clinic across town or even across the country. It is unlikely that data will be lost or cation accounting for the largest cost of any single medi- misplaced. With an appropriate back-up mechanism, it cation in this hospital is the drug odansetron, used to should serve as a permanent record of an individual’s control nausea in cancer chemotherapy patients. By pro- interaction with the health care system. Furthermore, gramming the order entry system to use as a default an with the availability of all the patient’s data, new views equally effective but less costly dose, the hospital was able and other summaries can be generated instantaneously. to save $100,000 over a one-year period (Bates, Kuper- Finally, with the potential for the incorporation of re- man. & Teich, 1994). The hospital is currently modify- minders and decision support, the likelihood of mistakes ing its order entry system to remind physicians of tests and omissions should decrease. ordered too frequently, such as a serum theophylline In addition to benefiting the individual patient, the level ordered within 24 hours of a previous one (David EMR is also likely to benefit the larger population. Clin- W. Bates, personal communication). ical research will likely be enhanced, as researchers have An additional measure to save costs has been the use easier access to information about patients that will in- of algorithms to assist decision-making. While compre- crease understanding of disease and its treatment. hensive expert systems such as QMR (Miller, Masarie, Screening and other preventive measures will become & Myers, 1986) are too time-consuming and complex easier to implement as patients of various attributes (i.e., for everyday use, focused decision support has been gender, age, presence of other risk factors) can be identi- shown to be effective. At Brigham and Women’s Hospi- fied and contacted. tal, an algorithm to determine the probability of chest A number of studies have documented some of the pain being due to myocardial infarction (and hence as- benefits of the EMR. The most comprehensive work in sist with the decision to admit a patient to the hospital) this area has come from Indiana University, where the has been shown to perform more accurately than physi- Regenstrief computerized medical record system has cians (Lee et al., 199 1). This allows patients most likely been developed over the last two decades. An initial clin- to have myocardial infarction to be admitted to the in- tensive care unit, with those less likely being admitted to and symptoms, radiology and other test interpretation, the regular hospital ward or being sent home. and procedure codes. Although some associate the Na- A problem with studies of EMR systems, however, is tional Library of Medicine’s Unified Medical Language that they tend to be site-specific (Dick & Steen, 199 1). A System (UMLS) with a comprehensive clinical vocabu- successful EMR not only requires the proper technology, lary, its goal is much more modest, to serve just as a but also commitment from both health care institutions meta-thesaurus linking terms across different terminol- and providers. Therefore, the same computer system ogy systems (Lindberg, Humphreys, & McCray, 1993). that is very successful in one institution may fail misera- A related problem to standards is that a large propor- bly in another. As a result, studies of EMR systems can tion of clinical information is “locked” in the form of be difficult to generalize from one institution to the next. narrative text ( Hripcsak et al., 1995 ). Although a num- Even within an institution, the EMR may be constantly ber of systems have been successful in limited domains changing as technology and the software itself evolve, (Sager. Friedman, & Lyman, 1987), the technology for making the results of a study of last year’s system less natural language processing (NLP) is still unable to in- meaningful. terpret narrative text with the accuracy required for re- Another problem in the assessment ofthe EMR is just search and patient care applications. While NLP is what constitutes “benefit.” Being a highly quantitative difficult for well-written published medical documents, field, medicine is likely to require showing some numer- it is even harder for medical charts that contain poorly ical benefit, such as reduced cost or increased quantity or structured, highly elliptical language, with frequent mis- quality of life. It is difficult, however, to measure user spellings to boot. Even if such language could be parsed, satisfaction for something as complex as the medical re- the lack of an underlying framework make its semantic cord. Furthermore, given the complexity of factors that interpretation more difficult (Evans, Cimino, Hersh, impact a patient’s outcome from an interaction with the Huff, & Bell, 1994). Some have proposed to solve this health care system, it is difficult to isolate variables, such problem with menu-driven data collection systems, but as those related to the EMR, as the cause of beneficial or these have generally been successful only in limited ar- adverse outcomes ( Rind, Davis, & Safran. 1995 ) . 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- Problems for the Electronic Medical Record curity and patient confidentiality. This problem, of A number of problems have been identified with the course, exists independent of the EMR, as a great deal EMR, including increased provider time, computer of medical information. abstracted from paper records, down time, lack of standards, and threats to confidenti- already exists in electronic repositories. Well-known pri- ality. Studies at the institutions described above (Bates, vacy experts have documented the threats that misuse Kuperman, & Teich, 1994; Tierney et al., 1993) have of this information has on personal privacy (Rothfeder, shown that electronic order entry increases the amount 1992). As noted above, the paper record is no barrier to of time physicians spend entering orders. In the study at duplication, as medical records are routinely copied and BWH (Bates, Boyle, & Teich, 1994), residents required faxed among health care providers and insurance com- 44 more minutes per day using computerized order en- panies already. While some fear the EMR will exacerbate try, although internal medicine residents using the order this problem, others note that computer-based records, entry gained half of that time back in cost savings else- with appropriate security, are potentially more secure where. Furthermore. the overall rate of user satisfaction and at a minimum leave a trail of documentation of of the system was very high. Developing means to those who access them. streamline order entry are now a priority. Most medical centers already have security. Employ- Another concern with EMR systems is computer ees given access are usually required to sign a confiden- down time. Although the threat of not having access to tiality statement indicating their understanding of the the right piece of information at the right time is real, the privacy of patient data. At most centers a password is increasing reliability of computer systems makes this less required to enter the system, although some institutions of a problem. At Oregon Health Sciences University, for also use a physical device, such as a key card. Virtually example, the daily scheduled down time has been re- all systems also keep an audit trail of who accessed which duced over the last several years from 1 hour to 10 min- patient and their data, providing a retrospective mecha- utes (Jim Elert, personal communication). Most hospi- nism for discipline should breaches of security occur. tal computer systems and the databases that run on them While there currently exists an array of technologies, are being designed for non-stop usage. including encryption and authentication. that could A more significant problem with EMR systems is the erect barriers between medical information and its un- lack of standards to interchange information. While a authorized use, it must also be noted that there is a trade- number of standards exist to transmit pure data, such off, as every computer user knows, between security and as diagnosis codes, test results, and billing information, ease-of-use. Since the pace of medical care in emergency there is still no consensus in areas such as patient signs settings as well as busy clinical areas can be hectic, pro- viders may become frustrated with layers of security. As order entry and quality ofcare. 02lu/i/?,X~unu~~l,)}irnt in Hculrh Curr. with the information field in general. policies and legis- 2. 18-27. Bell, D.. & Greenes, R. ( 1994). Evaluation of UltraSTAR: Perform- lation will need to be implemented that make the EMR ance of a collaborative structured data entry system. Procec~ding.s o/ usable but protect the individual’s privacy. the Itllt7 .A nmul Smpo.si7im on C‘o7npl1~r .4pplic~frtions in Mdicul (irrr(pp. 216-222). Washington, DC: Hanley & Belfus. Bria, W.. & Rydell. R. ( 1992). 7%~~pl7?,.si~ian-compllrcr connection: .A The Future of the Electronic Medical Record pructlcul pride 70 phjWia77 irmhwncn1 in l7ospitul7i~/i,7w7alion sys- /ems. Chicago: American Hospital Publishing. With the increased incentive to document and scruti- Dick, R., & Steen, E. (Eds.). ( I99 1 ). The cor??pfrrcr-hash puricnt rc- nize the delivery of medical care, the use of the EMR cord: . In es.wnriul rc,cl7no/o,el,./i7r pniirni care. Washington, DC: Na- should continue to increase. While this article has iden- tional .4cademy Press. tified many of its benefits, it has also listed some of the Evans. D., Cimino. J., Hersh. W.. Huff. S., & Bell. D. ( 1994). Toward drawbacks and impediments which need to be addressed a medical concept representation language. Jownul o~~tllc.,lnlcritnn ~\lcdi~ul Infimw/ics .-1ccociu7ion, I, 207-2 I 7. for the EMR to achieve its full potential. Greenes. R., Barnett. G.. Klein, S.. Robbins. A., & Prior. R. (1970). What are the challenges to developing the effective Recording, retrieval. and review of medical data by physician-com- EMR? First, the system must be beneficial to the user, puter interaction. h’:e~ Englum/ Jo7rrnul of’Mcdic7nr. 2X_), 307-3 15. the individual clinician who will be entering the data and Hripcsak. G.. Friedman. C., Anderson. P.. DuMouchel. W.. Johnson. using the results for patient care decisions. Thus, data S.. &Clayton. P. ( 1995). Unlocking clinical data from narrative re- ports: a study ofnatural language processing. Awx7l.s o/‘Intcrnu/M~~d- entry must not be excessively time-consuming or other- icim. 12-7, 68 I -68X. wise difficult, while obtaining information out must be Korpman. R., & Lincoln. T. ( I988 ). The computer-stored medical re- similarly fast and easy. Clinician involvement is crucial cord: For whom? Jorwrwl of’/hc.Imcric,an :Ifc~dic~ul.4s.sociu~ion. 2.55). for successful implementation of EMR’s (Bria & Rydell, 3454-3456. 1992 ). On the other hand, the system must not compro- Lee. T.. Juarez. G.. Cook. E.. Weisberg. M.. Rouan. G., Brand, D., & Goldman, L. ( 199 I ). 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