Electronic medical records: Creating the environment for change

As physicians become more advanced users of technology, they are exposed to a wider range of tools and technology-based clinical management systems: software and hardware intended to solve problems they face in clinical practice. However, the level of change required to implement these solutions is significant and requires a methodical review of work processes before implementation. Even in the most organized practices, it is unlikely that there has been a clear enough documentation of workflow relating to the management of specific clinical data.

When fully implemented, electronic medical record (EMR) systems allow health care providers to easily share patient information, legibly document patient visits, prescribe medication with built-in decision support in terms of drug-drug and drug-disease interaction warnings, and create automated patient-recall programs. The ability to view laboratory results within the EMR system significantly increases the richness of the clinical environment by allowing clinical decision support as part of chronic disease management.

Physicians will only be able to benefit from EMR systems with adequate preparation—just as when a vintner establishing a winery carefully selects a location and ensures that the weather, soil, and numerous other factors are exactly right before plant-ing the first seed. Once the seeds have been sown, a careful nurturing process takes place over a period of years to ensure the vines are healthy and able to produce excellent grapes for wine. This process is just beginning to take place in health care. Unfortunately, governments, medical associations, and physicians have done a poor job to date preparing the soil. Physicians are implementing EMR systems with varying degrees of success. Some systems have been quite successful while others have been complete disasters. We have attempted to create excellence without taking time to correctly evaluate and prepare the environment for change.

Barriers to change

Specific barrier[1] to the implementation of an EMR system include:

• Software immaturity. Software development is not advanced enough, despite extensive pre-implementation evaluation.
• Training issues. Both physicians and staff vary significantly in terms of computer expertise, ranging from novice to advanced users. 
• Privacy concerns. Difficulties arise over who will be entitled to access confidential patient information, and when EMR software architecture does not allow users to easily restrict access to certain providers. The successful adoption of EMR systems overall is limited by the lack of standards for communication, data storage, and information-sharing; the absence of consensus on privacy and security issues; and the need for federal approval of electronic signatures. It is difficult for vendors to develop products that conform to standards when the standards are continually changing. As end-users, we must have assurances that the data we create will be transferable. Why invest money, time, and energy in an EMR system if the data is not transferable to another system in the future? Fortunately, provincial ministries of health and national bodies are beginning to address these issues.

One of the major barriers to the widespread adoption of electronic medical record systems is the limited ability to access health information from external sources. “Interfaces” are pieces of software that allow different systems to communicate with one another and securely transfer information in one or two directions. Unless the user can access externally created information (such as lab test results), the EMR is restricted in its ability to provide a comprehensive view of patient care. Interfaces are complex and costly to develop. Usually the software vendor and the health information provider share the expense of development; however, the purchaser ultimately bears the cost. There is a need for a simplified standards-based approach to creating interfaces. In the future, intelligent “middleware” should allow different systems to speak easily to one another.
In order to be effective in a clinical practice setting, an electronic medical record system needs to integrate seamlessly with the process of care delivery, so the EMR system must provide a selection of information, tools, and data-entry mechanisms that allow the physician to access and input data in a manner that he or she prefers. These should include text entry, pen and tablet, speech recognition, and use of templates and clinical guides. The need to “double-task,” or work within both the EMR and the traditional paper world (e.g., provide a patient handout or review an X-ray report), reduces the value of the EMR system and decreases the likelihood that the EMR will be used effectively. One commentator[2] describes a scenario of two competing activities. Busy clinicians cannot defer their data entry to the end of the clinical encounter. They will, in fact, attempt to perform this task during the time spent with the patient. What will result is two competing information exchanges: physician-computer and physician-patient. As cognitive psychologists have shown, when a person performs two tasks simultaneously, neither of which is automatic, the performance of each task is poorer when compared with the performance of each task alone because the tasks compete for attention—a phenomenon called interference.

Efficiencies gained versus the cost

Value-gap
A “value-gap”[3] currently exists in terms of where physicians are and where they need to be in order to implement an EMR system. The value-gap can be defined as the difference between the efficiencies gained using the current level of technology in a specific medical practice and the total cost of making the jump to the next level of technology. The total cost must be measured in the time, expense, training needs, systems change, loss of productivity, and pain in implementing a new technology.

The value-gap is based on the concept that every new technology introduced into a practitioner’s office will initially reduce efficiencies and increase the cost of running the office. As staff become familiar with the system and work out the bugs, the office costs come down and efficiencies go up. Before the advent of EMR systems, technology introduced in a physician’s office affected only a few people and a single computer. Physicians could easily calculate the relatively small value-gap between the cost of the technology and the time it would take to make a difference in their practice. EMR systems drastically change the cost curve, as they require the simultaneous integration of many people and technologies. This is creating an almost incalculable value-gap between costs and productivity gains in the average practitioner’s office. What can be done to promote the adoption of technology and EMR systems and reduce the value-gap? There is a need for a trusted independent resource to provide guidance to physicians on software selection and best practices in the implementation of EMR systems and other technologies.

Preparing for change

An EMR system needs to be cost-effective if physicians are to pursue implementation. A recent BCMA paper proposes the establishment of a Physician Office System Program similar to Alberta’s POSP to support the computerization of physician offices in BC. The BCMA recommends an annual allocation of $8000 per physician to support IT costs in doctor offices.[4] While it is possible to demonstrate labor and physician-time savings through the use of an EMR system, government financial incentives are also needed to accelerate the uptake of this technology by physicians.

To date, very little time and energy have been committed to helping medical professionals develop the change-management skills needed for widespread adoption of EMRs. Steps need to be taken to create and nurture an environment for change. Despite the limitations and the barriers, we cannot afford to wait until all of the elements are perfectly aligned before we commit ourselves to this process. By taking part in information technology (IT) user groups, physicians can discuss technology in a manner that is appropriate to their needs within a specific community. I encourage physicians to identify community-based leaders and create IT user groups throughout BC in order to facilitate this process.

“Ideas for change are easier to implement and sustain if they further a vision the entire group shares.”[5]

Competing interests
None declared.

Alan Brookstone, MD

Dr Brookstone is a family physician in Richmond, BC. For the past 2 years he has used an electronic medical record system in his practice. He has consulted on health-related projects for Rogers Media, IBM Canada, and Canada Health Infoway. Dr Brookstone has also delivered presentations on 
electronic medical records and the use of information technology in medical practice at numerous conferences. He is a member of the Practice Solutions Advisory Team and sits on the editorial board of the Medical Post, Physicians Computing Chronicle, and Canadian Healthcare Technology.