The Electronic Medical Record:

Mirage or Panacea?
Jai Chakrabarti, MD

Over the last few years there has been a stampede of activity in the field of health information management. Paper
charts lying in silos of hospitals and doctors’ offices were considered a major barrier to better outcomes. The internet
was transforming society, and medical informatics woefully lagged behind. Many an expert opined that electronic
medical records would solve many of the current problems regarding healthcare quality and value. Healthcare
leaders were certain that the electronic medical record would pave the way to better value.

For every perceived business opportunity in society
there is an entrepreneur that fills the need. Enter the
EMR vendors armed with certified products that
promised the world. Portability, point and click options,
smart billing and more recently predictive analytics
emerged as the hot items to revolutionize medicine. All
the benefits still seemed to be in the future while the
costs were very much in the present – the proverbial
mirage of the future theoretical utopia.
What was forgotten in the heady rush to EMR was the
simple fact that there was no way doctors could stuff all
the meaningful information from a medical encounter
efficiently into an EMR. So entered the medical
scribe. Then entered the trained and certified HIPAA
compatible medical scribe! So the costs kept on rising
until we realized that all we had done was transform
paper silos into electronic silos. Meaningful inter-
operability of EMR systems was almost nonexistent
since different proprietary EMR brands could not
communicate with one another.
A Lack of Smooth EMR Interoperability -
Why?
EMR vendors were marketing products that did not
easily talk to each other. A recent report to the US
Congress by the Office of the National Coordinator for
Health Information Technology (ONC) revealed that
EMR vendors and big hospital systems were indeed
putting up barriers to the sharing of EMRs so that
they could keep patients in their own network (1). In
other words, the EMR has become a powerful business
tool for creating oligopolies rather than stimulating
competition and creating a level playing field for the
best providers of health services. There has been
recent concern that possible rivalries among EMR
vendors may be impeding digital information sharing.
The New York Times ran a very extensive article
regarding this important issue (1).
EMRs are Better as Billing Devices Than
Recording a Medical Encounter
Most of the EMR records that I have come across
(and I use one myself at my cardiology practice) have
not been able to preserve the essence of the medical
encounter between patient and physician. They look
like, and indeed are, billing devices that are festooned
with marginally relevant medical information. The
keen sense of focus encapsulated in a thorough medical
note requires extensive time spent typing into a record
or speaking into voice activated dictation software. But
time is a scarce commodity in today’s harried medical
environment. Hence the doctor whose eyes are focused
on the laptop screen and whose hands frantically
typing while you try to explain your pain. The essence
of a doctor-patient relationship is lost as the traditional
medical encounter becomes a digital experience.
The pressures of digital documentation have altered
the very nature of this important relationship.
The noted physician and author Abraham
Verghese stated the issue very succinctly,
continued on page 6

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“There is a kind of work that is involved in dealing
with critically ill patients and their families. It is costly.
It is costly to the psyche. It is costly to the system. The
notion that we can just shorten that time and fill it
with somewhat meaningless electronic medical record
time – first of all, it does not pay enough homage
to the importance of that kind of emotional labor,
and second, you are being forced to replace it with
something that we view as largely meaningless” (2).
Examination of the Benefits of EMR – A
Review of Published Evidence
It has been nearly eight years since the Hitech Act
of 2009 was passed to promote the adoption and
meaningful use of Electronic Medical Records. Almost
every hospital in the country has an EMR now. The
adoption costs have been astronomical. What has
been the published evidence of potential benefits? In
medicine, whenever an innovation comes to the fore
we must evaluate the objective published evidence for
outcomes compared to existing technology.
With regard to EMRs we should therefore ask the
following scientific questions: What is the published
evidence in the scientific literature for patient outcome
benefits as a result of EMR adoption? What is the
evidence of an increase in patient safety? What are
the savings to the healthcare system? What is the
cost-benefit ratio for society? Has the technology lived
up to its promise of inter-operability, portability and
transparency?
Patient Outcomes and EMR Use –
The Evidence
When I looked at the published evidence to date
regarding patient outcome benefits as a result of EMR
adoption, I did not find any randomized clinical trials
that looked at this question in a prospective manner
– which is the gold standard for evidence. However, I
did find a few observational studies. One particularly
important paper (See Reference 3) published in 2016
was a large observational study that queried the
America Hospital Association database and compared
hospitals with full EMR, partial EMR, and no EMR.
There was no improvement in patient outcomes
associated with the adoption of an EMR. To quote
the authors of the study, “These results indicate that
patients receiving medical and surgical care at hospitals
with no EMR system have similar outcomes compared
to patients seeking care at hospitals with a full EMR
system, after controlling for important confounders.
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To date, we have not yet seen the promised benefits
of EMR systems on patient outcomes in the inpatient
setting. EMRs may play a smaller role than expected in
patient outcomes and overall quality of care” (3).
Patient Safety and EMR Use – The Evidence
What is the evidence for increased patient safety as a
result of EMR adoption? Again, I found no published
prospective clinical trials looking at the question. All of
the data is retrospective. According to the Agency for
Healthcare Research and Quality (AHRQ), an AHRQ
research team analyzed relevant safety measures
in 2012 and 2013 using a large database (4). They
found certain patients had a better safety outcome
associated with the use of an EMR. These included
pneumonia patients who experienced 35% lower odds
of adverse drug events, 35% lower odds of hospital
acquired infections, and 25% lower odds of general
events. Patients for cardiac surgery, as well as general
surgery patients, also experienced some benefits. A
recent Carnegie Mellon study also found evidence of
increased patient safety when hospitals use advanced
EMRs based on data from Pennsylvania hospitals (5).
EMRs and Health System Cost Reductions –
The Evidence
EMR based billing software has the potential to
streamline efficiency for hospital systems. The
published literature in this regard refers to more
efficient capture of all relevant diagnostic codes. EMR
vendors often point to efficient billing and revenue
cycle management as a marketing plug when selling to
healthcare providers or large entities. However, rising
healthcare cost may be an unintended consequence of
this efficient billing technology. An article from the NY
Times addresses the issue of an increase in Medicare
cost, “The move to electronic health records may be
contributing to billions of dollars in higher costs for
Medicare, private insurers, and patients by making it
easier for hospitals and physicians to bill more for their
services, whether or not they provide additional care” (6).
A paper published online by a scholar from the Kellogg
School of Management examined in detail the effect of
EMR on hospital revenue. It raised the important issue
of lack of demonstrable cost reductions with EMR
use, and discussed the possibility that the increase in
revenue due to EMR based billing may be a factor.
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“The evidence of hospitals using EMRs to boost
revenue provides a potential explanation for the puzzle
of why EMRs do not generate cost reduction and
quality improvements as expected. HIT incentives
are aggressively pushing the whole US healthcare
industry to move into the IT era, while the guidelines
for coding practice and the way of monitoring, which
were designed to handle paper-based records, still lag
behind” (7).
EMR and Physician Workflow
Using EMRs was supposed to make things more
efficient for physicians and other healthcare providers.
A recent study in JAMA Internal Medicine found that
writing up a patient visit took more time than expected
and more than 60% of doctors stated that note writing
took longer (8). This was mainly due to the various
boxes that had to be checked as part of the EMR
format which often had little to do with important
healthcare issues. The survey found attending
physicians lost an average of 48 minutes a day while
residents lost about 18 minutes a day.
An NPR report on the same survey quoted an internist
from Georgia who stated the most important drawback
of current EMRs is the amount of clinically irrelevant
material that makes an EMR record is unwieldy,
When a specialist or hospital sends him a report about
a patient, it’s often so full of useless information related
to billing, medical coding, and rote checkoffs that
Lamberts struggles to find the nuggets he needs. “It’s
like getting a big box full of packaging material, and
there’s a thumbdrive in it,” says Lamberts (9).
Where Do We Go From Here?
Most EMRs are sub-optimally designed, are studded
with administrative and billing data, fail to capture the
essence of the medical encounter, increase physician
and provider time to complete records, and do not
talk to each other in a meaningful way. The published
evidence on improvement in patient outcomes and
safety is scant and almost all retrospective. EMRs have
the potential to increase healthcare system revenue by
more efficient billing and coding practices as well as
lead to efficient data analysis and population health
trend analytics. Paradoxically these efficiencies may
reduce their cost effectiveness.
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So what is to be done? We cannot be Luddites
and go back to our scratchpads.
Here are 6 things that need to happen soon for EMRs
to realize their true potential:
1. EMRs need to connect with each other so that
meaningful and extensive patient information can
be shared. I believe the ONC is working on making
this a condition of certification for vendors.
2. Hospital systems should be made to create
interfaces so that patient information can be easily
shared when necessary (not just by doctors in
their own network). This should become part of
the evaluation criteria for CMS certification for
hospitals. If a hospital is creating artificial barriers,
it is a disservice to patients and society.
3. Patients should be given complete access to their
medical records. Currently so called “webportals”
allow providers to tweak the amount of information
their patients can see regarding their own care.
4. EMR vendors should look at the ideal and
traditional medical record and use that as a
structure rather than efficient billing records.
EMRs should be more streamlined and focused
on healthcare information related to the medical
encounter. The billing and administrative data
needs to be secondary and should not interfere with
efficient medical workflow.
5. There has to be a periodic evaluation of the
total societal cost and the benefits accrued so far
regarding EMR adoption. The costs related to
EMR technology adoption continues to be huge. It
is time for a critical and dispassionate appraisal of
the benefits. What is the return on this investment?
EMR systems need to become cheaper and
more efficient as there is widespread adoption
of this technology. More competition needs to
be introduced in terms of the numbers of EMR
vendors.
6. Artificial intelligence systems and meaningful
diagnostic reasoning tools need to be introduced as
part of everyday work flow in healthcare, and these
need to be part of the next generation of EMRs. g
References on page 8
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References:

1.
https://www.nytimes.com/2015/05/27/us/electronic-medical-record-sharing-is-hurt-by-business-rivalries.html

http://www.medscape.com/viewarticle/884352(AbrahamVerghese-“We are responsible for HER Dysfunction)-

2.

Medscape August 22, 2017

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4902473/Medicine(Baltimore). 2016 May 95 (19): e3332.

3. 

Published online 2016 May 13. Doi:

https://www.ahrq.gov/news/blog/ahrqviews/020916.html Can Electronic Medical Records Prevent

4.

Harm To Patients

https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2503702
5.

Saving Patient Ryan - Can Electronic Medical Records Make Patient Care Safer?

http://www.nytimes.com/2012/09/22/business/medicare-billing-rises-at-hospitals-with-electronic-records.html
6.

Medicare Bills Rise As Records Turn Electronic – NY Times Sept 21, 2012

http://www.kellogg.northwestern.edu/faculty/b-li/JMP.pdf
7.

Cracking the codes: Do Electronic Medical Records Facilitate Hospital Revenue Enhancement?
By Bin Yang Li (Kellog School of Management)

http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1901114
8.

Use of Internist’s Free Time by Ambulatory Care Electronic Medical Record Systems

http://www.npr.org/sections/health-shots/2014/11/07/361148976/electronic-medical-records-built-for-
9.

efficiency-often-backfire

Note
A shorter version of this article was previously published on Dr. Chakrabarti’s LinkedIn page and is available
at https://www.linkedin.com/pulse/mirage-electronic-medical-record-jai-chakrabarti-md/

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