EMR in Primary Care
EMR in Primary Care – Boon or Boondoggle?
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Throughout my entire career as a family physician I have been a proponent of electronic health records. I was first introduced to both the amazing ability of computers to perform complex logical operations and the frustration of programming even the simplest of these operations during graduate school in the early 1970s. The family medicine residency at the Medical University of South Carolina used the COSTAR system (Computer Stored Ambulatory Record) developed at Harvard University and I became convinced that I could not practice properly without such a tool. When I finished residency in 1979 I thought it would be just a year or so until every practice would have an EMR, so I decided to take what I thought would be a one year “sabbatical” at the Lister Hill National Center for Biomedical Communications (LHNCBC), the research and development division of the National Library of Medicine at National Institutes of Health. The LHNCBC was (and still is) working on computerized systems to assist clinicians in information retrieval for better patient care. My “fellowship” lasted the next three decades doing research and development in what is now called clinical informatics, currently recognized as a subspecialty by the American Board of Medical Specialties. When President George W. Bush declared in his 2004 State of the Union address that every American would have an electronic healthcare record in ten years, I thought that would be the beginning of a jubilee and that I would never again have to search a patient’s paper chart.
The Federal government launched a financial incentive program for eligible hospitals to receive payments from the Medicare and Medicaid EHR Incentive Programs. The adoption of EMR in primary care practices increased from 5% in 2003 with about 25 vendors in the marketplace,  to 80% now with over 100 vendors of EMR systems.  Unfortunately, despite the approximately 20 billion dollars in Federal expenditure on the incentive program,  provider disappointment with the EMR systems they purchased is widespread. Multiple surveys have suggested that at least half of the physician users would not recommend their current EMR system.  A study to analyze this dissatisfaction, by my former colleagues at the LHNCBC suggests that most physician users find that rather than saving time, EMR use has resulted in their spending nearly an hour a day more in information recording and retrieval tasks. 
I have my own interpretation of these data. Since most clinicians are not IT developers, the software systems available have almost universally been designed by software engineers who have tried to analyze the clinical workflow process based on quite limited interaction with the end users of their products. To satisfy Federal requirements for “meaningful use”, the vendors have retrofitted their EMRs to address these functions separately rather than as a by-product of the patient care process. Most clinicians do not type well and the speech-to-text applications currently available do not function well in a noisy clinical setting. Clem McDonald’s survey indicates that trainees (residency/fellowship) are less dissatisfied and lose less time in working with EMR than do attending physicians; this is consistent with the bimodal age distribution in which the majority of primary care practitioners grew up before computer literacy was an essential life skill and most of the software developers (and medical trainees) grew up in a digital world and do not understand the analog mindset.
A recent American College of Physicians survey suggests that satisfaction and productivity with EMRs are directly correlated with the number of days devoted to training on the EMR system used, regardless of which product.  That has been my own experience; at initial installation in the large HMO where I practiced, practice productivity dropped dramatically, but once we learned the tips and tricks of the EMR system, the improvement in quantity and quality of patient care was dramatic even though the practice had been using a previous “homemade” EMR. If this old dog can learn, so can you! Hopefully the light I see at the end of the tunnel is not another train!
Charles Sneiderman, MD, PhD, DABFP
Medical Director, Culmore Clinic
Falls Church, VA
Published March 31, 2015
- Bates DW, Ebell M, Gotlieb E, Zapp J, Mullins HC. A proposal for electronic medical records in U.S. primary care. J Am Med Inform Assoc. 2003; Jan-Feb;10(1):1-10. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC150354/
- HealthIT.gov. Physician Adoption of EHRs. http://www.healthit.gov/newsroom/physician-adoption-ehrs. Accessed March 23, 2015.
- Manos D. EHR incentives climb to $19B. Healthcare IT News Web site. February 5, 2014. http://www.healthcareitnews.com/news/ehr-incentives-climb-19b. Accessed March 19, 2015.
- Perna G. Survey: physicians dissatisfied with EHR systems. Healthcare Informatics Web site. February 11, 2014. http://www.healthcare-informatics.com/news-item/survey-physicians-dissatisfied-ehr-systems. Accessed March 19, 2015.
- McDonald CJ, Callaghan FM, Weissman A, Goodwin RM, Mundkur M, Kuhn T. Use of internist’s free time by ambulatory care Electronic Medical Record systems. JAMA Intern Med. 2014;Nov;174(11):1860-1863.
- American College of Physicians. Physicians need more training on how to use EHRs. October 20, 2011. http://www.acponline.org/newsroom/physician_training_ehr.htm. Accessed March 19, 2015.