Successful implementation of an electronic medical record system to improve quality requires attention and effort from physicians at the start of the process, according to experts.
The more time physicians spend up front customizing the system to fit their needs, the less they will struggle later on, said Dr. Barry Bershow, director of quality and informatics at Fairview Health Services in Minnesota.
Dr. Bershow has seen first hand how effective electronic medical record tools can improve quality. At Fairview Health Services, which includes hospital and clinics across Minnesota, there has been significant improvement in quality measures in recent years. For example, screening for chlamydia has nearly doubled from 2004 to 2005, and there have been major improvements in asthma management and obesity screening.
Electronic medical records also can improve quality within small practices, he said. Before coming to work for the Fairview system 2 years ago, Dr. Bershow spent about 28 years working in a small family medicine practice affiliated with the Fairview system. In 1999, the practice became a pilot site to test Fairview's electronic medical record. The implementation proved successful, and the practice continues to use the system today.
Implemention of the EMR system led to reduction of staff by approximately four full-time employees and to improvements in quality, particularly in coronary artery disease and diabetes care, he said.
“It wasn't just because we were really good doctors,” he said. In fact, the performance improvements they saw were in areas where the EMR included clinical decision support and other prompts.
But Dr. Bershow doesn't downplay the tough transition to the system. It took 3 months before the physicians in the practice could start to go home at the same time they did before implementation. But at 6 months, half of the physicians were going home earlier than before, he said.
In the first couple of months, physician and staff satisfaction dropped, according to satisfaction surveys. At that point the excitement was gone, and they had yet to realize the benefits. But at 4–6 months, patients started coming in for return visits, and staff began to see efficiency in the system. At 6 months, all the results had improved including patient satisfaction, Dr. Bershow said.
One common mistake that physicians make is not building in the shortcuts at the beginning, he said.
Implemention of an electronic health record is not a guarantee of improved quality. In fact, a qualitative look at one suburban family medicine practice shows that a lack of communication about the goals of the EMR has actually led to a drop in quality improvement activities.
Jesse C. Crosson, Ph.D., of the New Jersey Medical School, Newark, and his colleagues, analyzed the EMR use of a family medicine practice in an upper middle-class suburban community in 2002 with follow-up in 2003 (Ann. Fam. Med. 2005;3:307–11).
Dr. Crosson and his team found that before the implementation of the EMR, the practice had used reminder stickers on their paper charts for screening, prevention, and disease management. But when the practice switched to an electronic system, the EMR's built-in reminders were disabled because they were too cumbersome, leaving the practice without any formal reminder system.
The lack of communication was a real obstacle in this practice, Dr. Crosson said in an interview. He recommended that physicians planning to implement an EMR meet early on with a broad group of people within the practice to figure out how to maintain existing quality of care system once the electronic system is in place. This could mean using duplicate systems during the transition period, he said.
One barrier to realizing the full potential of EMR systems is that physicians are trained to take care of one person at a time, Dr. Crosson said, and many of the innovative EMR functions help in caring for groups of patients. There needs to be a shift in the mind set of physicians in order to truly take advantage of the advances in technology, he said.
When shopping for an EMR that can aid in the collection and reporting of quality improvement measures, look for a system that can export the data in an electronic format, advised Dr. David C. Kibbe, director of the American Academy of Family Physicians' Center for Health Information Technology.
Health IT Lessons
Officials at the Agency for Healthcare Research and Quality are putting out some of the lessons learned from their health information technology projects. The information is available on the ARHQ Web site—
The Web site includes some of the early lessons from AHRQ-funded projects in a range of settings including health plans, hospitals, and small practices. The site also features links to more than 5,000 health IT resources, an evaluation tool kit to help implement health IT projects, and funding information.