Do electronic medical records improve quality of care?

Little evidence of improvement

However, there is still little conclusive evidence that EMRs make a substantial difference in the quality of care provided to patients. Some studies have had positive results; those studies often used custom-built systems rather than commercial software. Other studies have had negative results. The net result, according to recent systematic reviews, has largely been neutral.⁴ More important, there is still little evidence of improvement in patient outcomes.⁴ Evidence about physician efficiency⁵ and physician or patient satisfaction continues to be conflicting.⁶ The return on investment certainly seems underwhelming given the high hopes, floods of money, and eons of time invested by the entire health care system.

I admit to being one of the early enthusiasts. When I implemented an EMR in 2006, I was certain that this would improve care for my patients. In fact, I was so certain that I embarked on a research project as part of my master’s thesis to prove the fact. I compared provision of preventive services covered by a pay-for-performance program for a group of physicians implementing EMRs with a group continuing to use paper records. I looked at influenza vaccinations, Papanicolaou tests, colorectal cancer screening tests, and mammograms. Much to my dismay, the results were negative (0.7% less increase in preventive services provided for the group of physicians using EMRs).⁷ To my even greater dismay, the study won the 2012 Canadian Family Physician Best Original Research Article award. I also ran focus groups to find out what my colleagues thought of the EMR; there were many complaints about unexpected costs, software immaturity, system crashes, lack of connectivity with external systems, and lack of ongoing training to enable more advanced use.⁸ Although the interviews took place in 2008, the findings likely continue to resonate 7 years later for those of us using EMRs. There were some perceived benefits; for example, one physician stated, “I think patients are pleased. You know, ‘Oh, finally, you are in the modern age, I see. Good for you.’”

What can we do about it?

This now begs the question, why are most results negative and what can we do about this? Perhaps we should look no further than Ralph Nader’s classic book on car safety, Unsafe at Any Speed.⁹ In the 1950s, extra styling costs were $700 (US) per car, while safety measures amounted to about $0.23 (US) per car.¹⁰ The result was an appalling death toll, which was blamed on poor drivers. It seems unproductive to blame individual physicians for failing to use their EMRs properly to obtain better results; the system is not designed to produce better results. Perhaps incentives include too much emphasis on software details that are pleasing to the eye or to EMR regulators and funders, but that actually have little effect on care. Important but hidden benefits such as efficient and interoperable database design might not have received as much attention or funding.

There are very few incentives to record patient information so that the EMR works properly to help improve care. Many of our data are in free text, which is familiar and easy to enter. However, EMRs often need structured or coded data to enable automated recalls, point-of-care reminders, and computerized decision support.¹¹ The EMRs often have rudimentary reporting, data export, and analytic capabilities.¹² As well, running a large query can crash servers. The net result is that EMR applications help record care for one patient at a time, as was the case with paper records, rather than measure and monitor quality of care in practice populations.

In addition, responsibility for running EMR queries and analyzing and interpreting results often falls to the family physician. In most companies, executives are not tasked with running queries; analysts will do this in response to queries or to produce ongoing reports on company functioning and profits. Primary care teams, including physicians, will need similar personnel to help them with data management and analysis—this is starting to happen in Ontario and Alberta. This specialized function will require a move away from autonomous practice toward larger, more organized teams.