Commentary

The electronic medical record: Diving into a shallow pool?

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The rush to adopt the electronic medical record (EMR) has accelerated since the signing of the Health Information Technology for Economic and Clinical Health (HITECH) Act, part of the American Recovery and Reinvestment (ie, the Stimulus) Act of 2009. The HITECH Act provides incentives for physicians to adopt EMRs. However, I fear that our mad rush to complete adoption of the hodgepodge of currently available EMR systems may have unforeseen and unintended consequences. A skeptical look at several unresolved issues is warranted.

For a contrasting view

SO FAR, ELECTRONIC SYSTEMS ARE NOT INTERCONNECTABLE

More than 300 EMR systems are available, but only about two dozen account for most systems in use. 1 So far, these systems are not interconnectable, ie, they are unable to share information, so patients seen by different physicians may still have a fragmented electronic record.

EMRs can also be inefficient to use. Many systems require logging on to a separate, password-protected system to view images. These problems are likely to go away over time with Internet-based solutions under development by Google and others, but the current lack of interconnectivity leaves much to be desired.

ELECTRONIC RECORDS ARE AT RISK

EMRs are at considerable security risk. About 13% of medical offices in the United States are using some form of EMR. 2 A 1995 Harris poll revealed that 70% of Americans were concerned about the security of EMR systems. 3 In 2007, the New York Times reported that more than 250,000 patients each year are victims of medical identity theft. 4 A New Zealand survey revealed that 73.3% of patients were “highly concerned” about security and privacy. 5 Even more troubling to physicians is the reported 13% incidence of patients withholding medical information because of security concerns. Furthermore, multiple breaches of electronic records have already been reported, including an extensive breach of the Veterans Administration system. 6

DO ELECTRONIC RECORDS IMPROVE OR WORSEN THE QUALITY OF CAR E?

Proponents have repeatedly touted that EMRs improve the quality of medical care, and these claims have been used to accelerate the adoption of the EMR. The contention that EMRs improve the accuracy of billing, coding, and administrative functions is supported by considerable data; however, the evidence of the effect of EMRs on quality of care is mixed, with some information suggesting quality may not improve.

In an analysis of 750,000 patient records for a 2-year period as part of the National Ambulatory Care Survey, Linder et al 7 found that the EMR was superior in one quality area, worse in another area, and the same as paper-based records in 14 other areas. They pointed out that previous studies showing improved outcomes were mainly from large institutions with internally developed EMR systems, and that outcomes reported from these “benchmark” institutions may not be broadly applicable. 7 Linder et al concluded that use of electronic records “was generally not associated with improved quality of ambulatory care,” 7 and that increased use of EMRs does not imply an automatic improvement in quality of care. 7

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