Do electronic medical records improve quality of care?: No

Michelle Greiver

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Yes! Yes!
Declan P Fox

Published on: 09 November 2015
Re: Do electronic medical records improve quality of care?: No
Ian Pun

Published on: 26 October 2015
Re:The Right Tool for the job
Michelle Greiver

Published on: 26 October 2015
The Right Tool for the job
Paul V Mackey

Published on: 22 October 2015

Published on: (9 November 2015)
Page navigation anchor for Yes! Yes!
Yes! Yes!
Declan P Fox, Family physician
I struggled with several different EMRs back in the UK and found it stressful turning up for a locum in practice X and finding yet another EMR to get to grips with. Yet, the benefits were glaringly obvious. Notes made by doctors and other health care professionals were legible. Medication records were plain to see. Correspondence and lab reports were easy to find. Mis-filing, both of individual files and of reports in file...
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I struggled with several different EMRs back in the UK and found it stressful turning up for a locum in practice X and finding yet another EMR to get to grips with. Yet, the benefits were glaringly obvious. Notes made by doctors and other health care professionals were legible. Medication records were plain to see. Correspondence and lab reports were easy to find. Mis-filing, both of individual files and of reports in files, was a thing of the past. Tracking measurements in chronic disease was suddenly possible and relatively simple--how many remember evenings and weekends spent pulling paper charts and thumbing through pages and pages to do a basic audit?
Has no-one looked at the savings in secretarial staff time? Or are too many still thinking the same way as an older colleague once did when he said to me, no way am I buying a computer to give my secretaries an easier time? In the fee-for-service jungle, we pay good money for secretarial time and I for one would like it better used than running around chasing wads of paper.
I haven't read most of the research on this topic. The sort of benefits I see, and have been promoting since about 1990, are both obvious and more importantly readily measurable. Legibility of notes, to name but one.
While I sympathize with Dr Greiver's obvious disappointment in whatever EMRs she has been using, I would question the usefulness of research from 7 years ago. I read her paper and would have to say that perhaps she looked in the wrong place(s) for evidence of better outcomes. In my area, flu vaccines are given by pharmacists and public health nurses, PAP tests are done by nurses (mostly working for the health department, not directly for doctors), CRC screening is a government-run service with no direct physician involvement until a positive test and mammography is also a public service. These days in my area, it would be difficult to find four procedures less likely to give a positive result for EMR usefulness.
So here in north-western PEI, my staff and I have given up waiting for the all-singing all-dancing government-funded EMR and plan to instal OSCAR, at our own expense. We all have experience of using EMRs and we all experience daily frustrations with paper files which simply would not happen with a good EMR. Many of my colleagues in fee-for-service land have spent good money on EMRs and I don't think too many of them are misguided idealists.
I suggest that if we truly believe the matter requires further research, that we look firstly at the obvious benefits and then get into, as Dr Greiver says, the implementation. I agree that physicians should not be running routine searches. They mostly don't in the UK but the path to the useful EMR was nearly forty years long in the UK. Sincerely Declan Fox MB MRCGP CCFP
Conflict of Interest:
None declared
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Competing Interests: None declared.
Published on: (26 October 2015)
Page navigation anchor for Re: Do electronic medical records improve quality of care?: No
Re: Do electronic medical records improve quality of care?: No
Ian Pun, MD
I am a practicing family physician in Scarborough. I read your article about Electronic Medical Records do not improve quality of care in CFP Oct 2015. I feel maybe you just had a bad experience on your choice of EMR or vendor.
There has been great advances in the last five years on the adoption of EMR and usability. I get all my labs, imaging and even hospital reports electronically uploaded into my OSC...
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I am a practicing family physician in Scarborough. I read your article about Electronic Medical Records do not improve quality of care in CFP Oct 2015. I feel maybe you just had a bad experience on your choice of EMR or vendor.
There has been great advances in the last five years on the adoption of EMR and usability. I get all my labs, imaging and even hospital reports electronically uploaded into my OSCAR EMR.
EMRs are not used the same way as paper charts. It is a dynamic process.
I can proactively recall patients for Pap smears, FOBT, hepatitis B, diabetes followup etc by searching for patients who need them . I even upload my Cancer Care Ontario Screening Assessment Report in my OSCAR EMR for proactive recall. If there is a recall in a drug, I can search ALL MY PATIENTS to see who is taking it and recall them. I can recall patients who do not control their HbA1C. These features would be next to impossible or next to VERY TEDIOUS to do manually.
Also, I don't need anymore filing clerks - that used to misfile my paper reports ! I also save thousands of dollars on rental storage space for charts and cabinets!
I invite you to attend my talk about OSCAR EMR at the OCFP FMF ONTARIO COLLEGE OF FAMILY PHYSICIANS FAMILY MEDICINE FORUM on Friday Nov 13. at the Metro Convention Centre.
Dr Ian Pun family physician , Scarborough OSCAR McMaster EMR user and developer
You can find all the work I do on the OSCAR development here:
http://oscarmcmaster-bc- users.138173.n3.nabble.com/template/NamlServlet.jtp?macro=search_page&node=138173&query=ian+pun
Conflict of Interest:
None declared
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Competing Interests: None declared.
Published on: (26 October 2015)
Page navigation anchor for Re:The Right Tool for the job
Re:The Right Tool for the job
Michelle Greiver, Family Physician
I would like to thank Dr Mackey for his response to the Debate article. I also feel that his patients are fortunate to have him as their family physician; it is very evident that the quality of care they receive is important to him and that he uses the tools available to monitor and improve this.
I do not feel discouraged at all, and plan to continue working and doing research with and about EMRs and the data th...
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I would like to thank Dr Mackey for his response to the Debate article. I also feel that his patients are fortunate to have him as their family physician; it is very evident that the quality of care they receive is important to him and that he uses the tools available to monitor and improve this.
I do not feel discouraged at all, and plan to continue working and doing research with and about EMRs and the data they contain. However, I feel that we should have made much more progress after ten years of EMR implementation. I do not think the limited progress is isolated to any particular area or EMR vendor, rather, it is the overall functioning of our Health IT system that is problematic.
This is not to say that there has been a lack of progress; there has been improvement in the past few years, for example, electronic transmission of laboratory results, Diagnostic Imaging and hospital reports. As well, there are areas of excellent work; we need to hear more about those.
However, so much more still remains to be done. New medications are approved because they improve patients' health; a large Randomized Controlled Trial, the HOPE Trial in patients at high cardiovascular risk found that this medication reduced the risk of strokes and myocardial infarcts.
I cannot find evidence that use of EMR "A" leads to better health outcomes for my patients than EMR "B". We can do this type of study, it does not take a RCT; it takes data and analytics to enable us to generate the evidence. Even if EMR "B" is found to be inferior, we can look at the differences between the two and help our colleagues using EMR "B" by pushing for implementation of useful features through regulations and market forces.
You cannot improve what you do not measure. To improve outcomes for our patients and our health care system, we need data, we need analytics, we need accurate and fair reporting using EMR data and other data sources.
I am not alone in asking for progress towards a more Evidence- Informed Health Information Technology system. I strongly feel that all of us share the same goal, that of using our EMRs to maximize benefits for the patients who have trusted us with their care. The actions needed to ensure that this comes to pass will need to be collective; EMR vendors and the Health IT system need to support these goals by more consistently enabling all of us using their products to monitor and improve the care we provide to our patients.
A wise clinician recently wrote, "Data orientation, the relentless pursuit of excellence, and a habit of inquiry are all second nature to clinicians" (Bohmer R, Leading Clinicians and Clinicians leading, NEJM 2013). Our profession is fortunate in having such Clinician Leaders; it is time for us and our Leaders to collectively demand better from our EMRs.
Conflict of Interest:
None declared
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Competing Interests: None declared.
Published on: (22 October 2015)
Page navigation anchor for The Right Tool for the job
The Right Tool for the job
Paul V Mackey, Physician
First my sympathies for Dr Greiver. The EMR she appears to have been forced to use can only be described as a 'dog' if it has been so functionless as to temper her early adopter enthusiasm. To have a query crashing a server is, frankly, pathetic and inexcusable.
Last week I had a patient get lost (another story) on the way to her medical exam so, suddenly, I had a spare 20 mins. Just that morning a patient enc...
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First my sympathies for Dr Greiver. The EMR she appears to have been forced to use can only be described as a 'dog' if it has been so functionless as to temper her early adopter enthusiasm. To have a query crashing a server is, frankly, pathetic and inexcusable.
Last week I had a patient get lost (another story) on the way to her medical exam so, suddenly, I had a spare 20 mins. Just that morning a patient encounter had reminded me that, for multiple reasons, our Diabetes tracking had fallen to the bottom of the "to do" list. The patient apologized for not following up. I had to apologize to him for not being flagged for recall. So, in my "spare" 20 mins I ran a Diabetes recall report (no crash) for our clinic group, selected my own patients, sorted them by date of last A1C (though I could have chosen any of a number of metrics) then started messaging my MOA to remind those who had fallen off a bit. I was also able to identify those few patients who had moved away and thus "remove" them. I was also able to use the EMR to check which patients had a current standing order at the lab, and generate a new one for those that didn't.
Can I prove that any of this will improve patient care? Like all Family Practitioners our patient populations and the intervention group are too small to show a benefit that will satisfy the statisticians and the meaningful use mavens. So all I can hope is that my EMR driven, _personalized_ care will maybe help a few of _my_ patients. What I am certain of is that none of this could be achieved in a paper chart so easily.
As described in Dr Ladouceur's editorial, the EMR is but a tool. I wouldn't expect to hear anything with a toy plastic stethoscope but my electronic variety has enabled me to manage the challenges of my hearing deficit. A poor tool foisted upon the end user because it serves administrative or government wants and needs rather that the necessities of the end user (or the receiver: the patient) will continue to engender unhappiness, resistance and poor outcomes. As the Einstein Internet meme alludes, it is insane that we are still having this discussion AND that governments and administrations continue to repeat the mistakes of the past yet expect different outcomes. Personally I would never 'go back' from our EMR to the inefficiencies and deficiencies of the paper chart but, then, our EMR is one we chose (and switched to) to meet our needs and the needs of our patients, in defiance of government coercion. Our EMRs (and our ability to use them) are probably already a more critical tool than our stethoscopes (think about it: which do we use more in a working day?) so why would we let those who don't actually use them direct which we should use (and how we should use it).
So, I am hoping that Dr Greiver's enthusiasm can be restored by allowing her to have the right tool and the control over how to use it for the benefit of her patients (and herself).
Conflict of Interest:
I am a volunteer board member of Applied Informatics for Health Society (AIHS), the non profit that manages the EMR, Medical Office Information System (MOIS).
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Competing Interests: None declared.