Commentary

The electronic medical record: Learning to swim

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As Dr. Hanlon accurately notes, evidence that the EMR improves the quality of care is mixed so far. He is concerned that most of the studies showing improved outcomes came from “benchmark” institutions, and that the results may not be broadly applicable. Such pessimism is unwarranted, given that the EMR is in its relative infancy and the motivation to improve quality of care is paramount, especially in this era of health care reform. While benchmark institutions are in an ideal position to do the studies on quality, there is no reason to assume that the results will not be applicable to other institutions as well.

EDUCATION: AN AREA FOR INNOVATION

Dr. Hanlon notes that research on EMRs for medical education is in its infancy. But infants grow rapidly. While it may be true that students might have to learn to use different EMR systems at different institutions, these students have grown up with rapidly changing computer systems and can learn and adapt at a remarkable rate. Therefore, education is a wonderful area for innovation and research on the EMR. It is not a reason to fear the EMR or the present diversity of EMR systems.

ACCURACY CAN BE IMPROVED

Dr. Hanlon is correct that the problem of cutting and pasting of previous notes, potentially propagating an initial error (so-called high-risk copying 3) is profound within the EMR. But I prefer to look at this as an area for innovation— such as nonerasable tags to identify copied material.

While errors in medication lists are possible, especially if practitioners use cut-and-paste methods and thus perpetuate a previous error, systems and workflows are being developed to overcome such problems. Some of these include special alerts when certain high-risk drugs are ordered, drop-down menus with drug dosing included, and links to databases that allow quick access to information on drug interactions.

And again, medication errors are not unique to the EMR. They also occur in paper charts as a result of photocopying, illegible handwriting, and transcription errors.

Compared with the paper chart, the EMR is more legible, and the ability to instantaneously transfer unchanged important and valid information potentially enhances the completeness and logic of a given note and provides the physician more time to spend evaluating (and looking at) the patient. So, rather than focusing on the negatives of the current problem of cutting and pasting, I prefer to focus on how to improve it. That is, how can we make the information in the EMR more accurate, catch errors, and then make the latest information easily accessible to users?

STAYING FOCUSED ON THE PATIENT, EVEN WITH A COMPUTER IN THE ROOM

A major complaint by patients and caregivers is that using an EMR makes the physician focus on a computer screen rather than looking at the patient. This concern is valid, but I think we can learn to stay focused on the patient, even with a computer in the examination room, and still take advantage of everything technology has to offer.

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