Explaining the epic failure of EMRs

It is no news a lot of doctors like to stick up a rather snotty nose to EMR. The defenders of the EMR tend to label such doctors as archetypal Luddites, sticking to their archaic ways and unbecoming of change and the new times. But as is usually the case with any two heated but opposite arguments, the truth likely lies somewhere between the two extremes.

On an objective basis, there is no denying that automatisation of medical record keeping is the new way forward. In theory, if the machine could keep records for you and give it back to you when and where you want it, thus freeing up valuable time for the patient encounter, that should be winsome for everyone. That alas, is a vision of the EMR utopia, and let alone being anywhere close to such utopia, it is difficult to ascertain if we are even set in the road leading us there.

Sometime ago, exasperated at the sheer waste of time that the clunky new discharge module was causing because it would not work the way it is supposed to (my hospital is means challenged, so they are building a patchwork of cheapskate EMR suite on top of their legacy system from the 90s, just to placate the gods of CMS), I complained to the IT guy that the thing barely works! The guy was sympathetic and said, “look I know the discharge module sucks, just bear with it until the end of the year when we should be able to weed out the bugs.”

But that’s not all, I said, even if it were working just the way it is supposed to, the discharge still takes me longer than what it used to with paper. “That’s something you will have to learn to live with,” he retorted. “Computer records do take a longer time than paper, and there is nothing I can do to change that.”

Right there, I think is where EMR loses a lot of ground against paper records. At any practice, time is the most valuable resource, and anything that doesn’t offer a straight off benefit to save time will have a hard time being adapted. Add to that the inertia people have about their old ways and you have a deal breaker right there.

Comparison with paper-based records

Paper-based records are still by far the most common method of recording patient information for most hospitals and practices in the U.S.^[2] The majority of doctors still find their ease of data entry and low cost hard to part with. However, as easy as they are for the doctor to record medical data at the point of care, they require a significant amount of storage space compared to digital records. In the US, most states require physical records be held for a minimum of seven years. The costs of storage media, such as paper and film, per unit of information differ dramatically from that of electronic storage media. When paper records are stored in different locations, collating them to a single location for review by a health care provider is time consuming and complicated, whereas the process can be simplified with electronic records. This is particularly true in the case of person-centered records, which are impractical to maintain if not electronic (thus difficult to centralise or federate). When paper-based records are required in multiple locations, copying, faxing, and transporting costs are significant compared to duplication and transfer of digital records.^{[citation needed]} Because of these many "after entry" benefits, federal and state governments, insurance companies and other large medical institutions are heavily promoting the adoption of electronic medical records. Congress included a formula of both incentives (up to $44K per physician under Medicare or up to $65K over 6 years, under Medicaid) and penalties (i.e. decreased Medicare/Medicaid reimbursements for covered patients to doctors who fail to use EMR's by 2015) for EMR/EHR adoption versus continued use of paper records as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009.^[3]

One study estimates electronic medical records improve overall efficiency by 6% per year, and the monthly cost of an EMR may (depending on the cost of the EMR) be offset by the cost of only a few "unnecessary" tests or admissions.^[4][5] Jerome Groopman disputed these results, publicly asking "how such dramatic claims of cost-saving and quality improvement could be true".^[6]

However, the increased portability and accessibility of electronic medical records may also increase the ease with which they can be accessed and stolen by unauthorized persons or unscrupulous users versus paper medical records as acknowledged by the increased security requirements for electronic medical records included in the Health Information and Accessibility Act and by recent large-scale breaches in confidential records reported by EMR users.^[7][8] Concerns about security contribute to the resistance shown to their widespread adoption.

Handwritten paper medical records can be associated with poor legibility, which can contribute to medical errors.^[9] Pre-printed forms, the standardization of abbreviations, and standards for penmanship were encouraged to improve reliability of paper medical records. Electronic records help with the standardization of forms, terminology and abbreviations, and data input. Digitization of forms facilitates the collection of data for epidemiology and clinical studies.^[10][11]

In contrast, EMRs can be continuously updated (within certain legal limitations – see below). The ability to exchange records between different EMR systems ("interoperability"^[12]) would facilitate the co-ordination of healthcare delivery in non-affiliated healthcare facilities. In addition, data from an electronic system can be used anonymously for statistical reporting in matters such as quality improvement, resource management and public health communicable disease surveillance.^[13]

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Explaining the epic failure of EMRs

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