Original Research

Does the Use of Electronic Medical Records Improve Surrogate Patient Outcomes in Outpatient Settings?

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BACKGROUND: We reviewed the evidence regarding the effectiveness of electronic medical records (EMRs) as tools for improving surrogate patient outcomes in the outpatient primary care setting.

METHODS: We searched the MEDLINE database (1966-1999) to find relevant articles for inclusion in the systematic review. Reference lists of retrieved publications were also searched for relevant citations. We included original published reports of all prospective studies evaluating the use of hybrid or complete EMR systems as a method of improving surrogate patient outcomes in the outpatient primary care setting. Criteria for evaluation included the use of a random study group assignment, appropriateness of control group, blinded assessment of outcomes, number and reasons for withdrawal of subjects, and attempts to minimize confounding interventions.

RESULTS: Seven prospective trials of complete EMRs and 9 prospective trials of hybrid EMRs were located. Most evaluated the impact of EMR-generated reminders on provider and patient compliance with health maintenance interventions. Findings were equally positive for both complete and hybrid EMRs, and all but 1 trial reported positive results. However, the methodologic quality of the trials was modest. Design problems included lack of concurrent control groups, non-blinded outcome assessment, and the presence of potentially confounding concurrent interventions.

CONCLUSIONS: Evidence from published trials suggests that utilization of either complete or hybrid EMRs can improve some surrogate outpatient care outcomes. However, rigorous trials that evaluate their impact on morbidity and mortality, and employ current technologies are required before widespread adoption of EMRs can be confidently recommended.

Clinical question

In the outpatient primary care setting, can the use of electronic medical records lead to improved surrogate patient care outcomes?

The handwritten record has been the standard way of documenting medical information since the 19th century.1 However, the rapid evolution of computer technology has led to the development and use of electronic medical records (EMRs) during the past several decades.2,3 EMRs have many theoretical advantages over paper charts, including: the ease of transfer of information between medical providers and facilities;1 the ease of querying databases and tracking information for research and quality improvement;1 the ability to monitor for adverse events, such as drug interactions, at the point of care;4 and the ability to expand the range of documentation in medical records by incorporating multimedia elements, such as digitized photographs, heart and lung sounds, and even patient interview video clips.5

However, while the potential for EMRs to transform medical care has been recognized since at least the 1970s,6 implementation of EMRs in the outpatient primary care setting has been disappointingly slow.2 There are many reasons for the slow adoption of EMRs; cost and the complexity of health care delivery systems are major factors.7 Even so, it is likely that more primary care physicians would make the leap to electronic records, despite high initial costs and complexity, if evidence suggested their use could improve patient care. Therefore, we conducted a systematic review of the literature to answer the question: In the outpatientprimary care setting, does the use of EMRs lead to improved surrogate patient outcomes?


Throughout 1998 and 1999, each author independently searched the MEDLINE database (1966 through 1999) via the University of California Digital Library interface8 to find relevant articles for inclusion in the systematic review. Each author used Medical Subject Headings (MeSH), key words, and publication type restrictions, in all possible combinations, to conduct the literature search.* The lists of citations retrieved were compared, and citations appearing on either list (or both) were reviewed in detail as described below.

Initial Research Question. Our initial goal was to review the original reports of all prospective studies about the impact of EMRs on patient morbidity and mortality in the outpatient primary care setting. We limited our systematic review to papers involving hybrid or complete EMR systems used by primary care physicians in the outpatient setting. A hybrid EMR was defined as a system that includes integrated access to all of the following resources: clinical laboratory and radiology data; master problem lists; inpatient and outpatient encounter diagnoses and dates; prescriptions; and billing information. Physician notes are not included in such systems; they are kept in traditional paper format. A complete EMR was defined as a system that includes all of these resources, plus full outpatient encounter progress notes, histories and physicals, and consultation notes. Some complete EMRs function as truly paperless records, while others involve the use of paper encounter forms from which information is later entered into the EMR by data entry personnel. Readers interested in the results of studies involving more limited-practice computer systems are referred to 2 recent systematic reviews.9,10


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