The unaided human mind simply cannot process the current volume of clinical data required for practice, especially relevant given the broad scope of primary care. Tolentino suggests that “voltage drops” occur in the transmission of medical knowledge.25
As information becomes obsolete, it is not refreshed, and new knowledge cannot be integrated. Thus, physicians take “short cuts,” using clinical experience and heuristics rather than pursuing organized investigations. The advent of genomics will only make this problem worse.
Primary care providers have many important information needs that are not being met.26
Studies of these needs27–29
suggest that physicians have about 8 unanswered questions for every 10 ambulatory visits. If physicians adopt EMRs, one benefit may be to improve access to electronic information resources.
Because of their integrating and coordinating function, electronic records are especially important for care of certain populations, such as rural residents, children, pregnant women, lactating mothers, and the elderly, who depend heavily on primary care physicians.30
Poor and underserved populations may require different primary care services.
The dream of converting from paper to electronic charts has a long history.31–33
Three recent developments make it time for this dream to become a reality. First, given the widely dispersed nature of primary care services, the Internet can now play a critical role in this transformation.34
High-speed connections from physician offices can provide web-based clinical tools using an application services provider (ASP) model (see Table 1). Second, the speed and power of readily available computers are increasing and their costs decreasing. Third, computers and software are evolving rapidly, so that mobile devices can be easily linked to wireless medical networks.35
Handheld computers can be useful sources of drug and other information36
and in the near future will likely help to extend desktop networks.
Although the full range of EMR benefits will not become clear until more systems are implemented and more processes computerized,37
EMR systems can already improve efficiency and quality. The costs of “chart pulls” can be eliminated, and dictation costs can be substantially reduced. Providers can also receive decision support regarding the costs and selection of drugs, laboratory tests, and radiographic studies. By making a number of changes identified by EMR data, such as identifying the least expensive drug within a class, providers were able to reduce drug costs by 18% (personal communication, J. M. Overhage, September 2001). Several studies showed that displaying charges for tests,38
the last test result of that type,39
and prediction whether a specific future result would be abnormal given prior results40
independently reduced laboratory test use by 10–15%. The EMR is available 24 hours daily, 7 days a week; can be viewed by more than one user at a time; is available from remote locations; can nearly always be found; and is legible. A covering physician can rapidly get a sense of a patient’s problems by quickly reviewing those problems, medications, and recent notes in the EMR.
Even more than improving efficiency, quality may be the greatest benefit of computerization. Computer-ization of reminders and prevention guidelines benefits patients.41
Reminders are also effective in care of chronic conditions, such as diabetes (Figure 2).42
Computerization of medication prescribing improves safety; in one study of inpatients, the medication error rate was reduced by more than 80%.43
Com-munication between patients and providers appears to represent a particular problem in outpatient care,44
and computerization may be helpful in this domain. Another quality improvement benefit will likely come from monitoring and tracking abnormal results and ensuring that appropriate follow-up occurs. Moreover, electronic records can be linked with public health surveillance, which may be extremely important in emergencies such as a bioterrorism attack or an epidemic.23
Figure 2. “Face Sheet” for a typical patient. When a primary care provider sees a patient, the EMR typically provides a snapshot of key information, including but not limited to the patient’s demographics, problem list, medications, and (more ...)
To deliver the same or better care at similar or lower costs, we need to measure quality routinely. The public and payers are increasingly demanding quality measurement,45
which becomes vastly easier when using EMRs, since aspects of chart reviews can be automated.46
EMRs facilitate sharing medical information between patients and providers.12
A related variety of patient-centered and community-based EMR experiments are ongoing.46
Electronic medical records will also have important benefits for specialty care. For example, poor communication plagues the current referral process47
and could be ameliorated through computerization. Poorly coordinated care can lead to adverse drug events, unnecessary tests and treatments, and higher costs. Critical linkages between specialty services and primary care cannot be established until the EMR is developed sufficiently to interface across a spectrum of settings.