Does the Use of Electronic Medical Records Improve Surrogate Patient Outcomes in Outpatient Settings?
Implications for further research
Because of the rapid pace of technology, some of the EMRs discussed in our paper are legacy systems and do not accurately reflect those that are currently on the market. To prevent this data lag phenomenon in the future, efforts must be made to report findings generated from EMR implementation projects as quickly as possible. This goal is likely to be realized if academic health centers make EMR research and implementation a high priority. Another crucial research issue concerns the relative merits of EMR components. For example, is the presence of electronic progress notes in complete EMRs associated with incremental clinical value beyond that provided by hybrid systems? Current EMR manufacturers appear to be focusing on complete systems,32 many of which involve direct physician entry of encounter data and orders, which might decrease physician time efficiency. Yet the positive findings of the Regenstrief and Ottawa trials imply that a great deal of the benefit of EMRs may derive from the coordination of laboratory, radiographic, diagnosis, medication, and administrative data (all entered by nonphysician support personnel) onto a single platform. If physicians are to embrace the financial and encounter time costs likely to be entailed by currently marketed complete EMR systems, comparative trials demonstrating tangible advantages compared with hybrid systems will be required. Such data are particularly important because physicians in several studies cited lack of time as a major reason for ignoring the EMR prompts.22-29
The design of such trials will need to be carefully considered if the potential benefits of complete EMRs are to be discovered. EMRs are promising tools for raising the possibility of relatively uncommon diagnoses on the basis of computer-algorithmic detection of clinical data constellations from a database. A future study might examine the ability of a complete EMR system to recognize not only that a patient has poorly controlled hypertension but also that the patient is older than 65 years; has concurrent diagnoses of tobacco abuse and peripheral vascular disease; has a creatinine level of 1.7; is on an optimal triple-drug antihypertensive regimen including a diuretic; had stated compliance with that regimen at his last outpatient encounter; and had an abdominal bruit on recent physical examination. The EMR, recognizing this constellation via a pre-programmed detection algorithm, would generate a provider prompt detailing the relatively high probability of the diagnosis of renal artery stenosis as a cause for the patient’s uncontrolled hypertension. If the physician could then compare the diagnostic performance of this complete EMR with that of a hybrid EMR running a similar algorithm, the potential value of electronic progress notes could be clarified.
The use of either hybrid or complete EMRs in the outpatient primary care setting can be cautiously supported on the basis of their ability to improve provider and patient compliance with screening interventions, as well as to improve prophylactic and active problem treatment rates. However, only a small range of clinical problems has been studied, and a great deal more evidence is required before firm recommendations can be made regarding the relative merits of these systems or specific products. At this time there is no direct evidence that the use of EMRs is associated with reduced patient morbidity and mortality in the outpatient primary care33 setting. However, there is also no evidence to suggest that their use is harmful to patients or reduces patient satisfaction with care. Therefore, other potential benefits of EMRs, such as improved work flow, more consistent availability of records, and greater legibility of information, may be evaluated without concern for adverse impact on patient care.
Studies of EMRs that employ current technologies, examine their impact on patient morbidity and mortality, and are conceptualized to investigate the most likely advantages of electronic systems are urgently needed. Finally, rigorous cost-effectiveness analyses should accompany these studies to help family physicians determine the feasibility of implementing EMRs in their practices.
