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1293
Electronic Medical Records in the American Health System:
challenges and lessons learned
Registros Eletrônicos de Saúde no Sistema de Saúde norte-
americano: desafios e lições aprendidas
Resumo Os registros médicos eletrônicos (RME)
têm sido apontados como uma solução para muitas
das deficiências dos sistemas de saúde. O objetivo
deste ensaio é revisar a literatura pertinente e apre-
sentar exemplos e recomendações de várias déca-
das de experiência no uso de registros médicos na
atenção primária à saúde, de maneira a ajudá-los
na organização de seus processos de trabalho para
melhorar o atendimento ao paciente. Observou-se
que problemas consideráveis resultam da falta de
interoperabilidade e padronização de interfaces
entre esses sistemas, prejudicando a colaboração
efetiva e a troca de informações no atendimento
a pacientes complexos. É extremamente impor-
tante que políticas regionais e nacionais de saúde
sejam estabelecidas para garantir a padronização
e interoperabilidade dos sistemas. A falta de inte-
roperabilidade contribui para a fragmentação do
ambiente de informações. O prontuário eletrônico
(RME) é uma tecnologia disruptiva que pode revo-
lucionar a maneira como cuidamos dos pacientes.
Foi demonstrado que o RME melhora a qualidade
e a confiabilidade na prestação de serviços de saú-
de quando implementada adequadamente. Uma
atenção cuidadosa ao impacto do RME nos fluxos
de trabalho clínicos, a fim de aproveitar ao máximo
o potencial do RME para melhorar o atendimento
ao paciente, é a principal lição de nossa experiência
na implantação e uso desses sistemas.
Palavras-chave Registros eletrônicos de saúde,
Atenção primária à saúde
Abstract Electronic medical records have been
touted as a solution to many of the shortcomings
of health care systems. The aim of this essay is to
review pertinent literature and present examples
and recommendations from several decades of ex-
perience in the use of medical records in primary
health care, in ways that can help primary care
doctors to organize their work processes to im-
prove patient care. Considerable problems have
been noted to result from a lack of interoperabili-
ty and standardization of interfaces among these
systems, impairing the effective collaboration and
information exchange in the care of complex pa-
tients. It is extremely important that regional and
national health policies be established to assure
standardization and interoperability of systems.
Lack of interoperability contributes to the frag-
mentation of the information environment. The
electronic medical record (EMR) is a disruptive
technology that can revolutionize the way we care
for patients. The EMR has been shown to improve
quality and reliability in the delivery of healthcare
services when appropriately implemented. Care-
ful attention to the impact of the EMR on clinical
workflows, in order to take full advantage of the
potential of the EMR to improve patient care, is
the key lesson from our experience in the deploy-
ment and use of these systems.
Key words Electronic medical records, Primary
health care
Robert S. Janett (https://orcid.org/0000-0002-8458-7296) 1
Peter Pano Yeracaris (https://orcid.org/0000-0002-4017-3171) 2
DOI: 10.1590/1413-81232020254.28922019
1 Cambridge Health
Alliance. 237 Hampshire
Street. 02139 Cambridge
Massachusetts USA.
robjanett@nefeshhealth.com
2 Care Transformation
Collaborative Rhode Island.
Providence Rhode Island
USA.
ARTIGO ARTICLE
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Janett RS, Yeracaris PP
Introduction
Electronic medical records have been touted as a
solution to many of the shortcomings of health
care systems1-3. Others have criticized the move
toward the electronic medical record (EMR) as
a threat to the physician patient relationship, to
patient privacy, and as an additional adminis-
trative burden to the health system contribut-
ing to physician burn-out4,5. A modern EMR is
not simply a digitized paper chart. Rather, it is a
digital application that can actively interact with
providers and patients and is composed of a se-
ries of data fields that lend themselves to analysis,
processing, and reporting to support communi-
cation, appropriate clinical interventions, quality
improvement, and patient safety.
As authors of this article, we both have prac-
ticed medicine using paper charts and were pres-
ent for the painful transition from paper to elec-
tronic records. We are primary care physicians
and have been users and implementers of elec-
tronic health records in public and private health
systems, locally and regionally in the northeast
United States. The first section of this paper
will describe the evidence for the benefits and
drawbacks of electronic medical records. In the
second section we will then describe, from the
literature and our experience, some of the ways
that electronic records can be optimally used to
support better health care delivery for individual
patients while simultaneously improving health
care delivery to populations.
There is no perfect electronic medical record
system, but there are features of systems that have
been shown to improve reliability, quality, and ef-
ficiency over time. There is no better tool than an
EMR to integrate patient care among members
of the care team at a specific facility (horizontal
integration), and among providers and various
facilities at the primary, secondary, and tertiary
levels of care (vertical integration). A high func-
tioning EMR helps reduce fragmentation in the
care delivery system and this improves quality
and efficiency by reducing gaps in care. An EMR
can offer reminders of important interventions
that are needed at the time of an office visit and
can track and flag patients who do not present
themselves for follow up care in an appropriate
timeframe.
At the same time, EMR systems are costly
to implement and to maintain, and can also be
challenging because an EMR impacts virtually all
of the workflows and care processes in a clinical
environment.
The EMR is particularly useful in primary
care settings, especially because primary care is
the locus of most care coordination activities
that occur in health systems. Comprehensive in-
tegrated primary care6-8 is perhaps the most sig-
nificant contributor to reform of the American
health system. Electronic records are an essential
component of this evolving care model and are
designed to support many of the unique features
of robust primary care, as we will describe in
detail. Key features of this comprehensive care
model9 include empanelment of patients with
specific provider teams, advanced access to ap-
pointments, team-based multidisciplinary care,
shared responsibility among team members for
providing evidence-based patient interventions
in a reliable way, shared access to clinical infor-
mation across members of the care team, elec-
tronic communication with patients, checklists
to support the closure of gaps in care at the time
of the office visit, and active outreach to patients
who do not visit the office but who are identified
to have gaps in care. Moreover, coordination of
complex care with specialists and hospitals in-
volves shared access to clinical information and
secure channels of communication.
Evidence for the Impact of the EMR
on Medical Practice
There is ample evidence from the global lit-
erature on the impact of the EMR on clinical
practice. A systematic review10 showed that adop-
tion of an EMR improved structural and process
components in primary care, with less clear evi-
dence of the EMR’s impact on outcomes. A 2006
study on pediatric practices11 showed that larger
practices were more likely to adopt an EMR than
smaller practices because of cost concerns, and
the lack of decision support features in EMRs
of that era limited the impact on quality of care.
Kaiser Permanente, the largest private integrat-
ed health system in the United States, showed
that implementation of the EMR significantly
reduced demand for primary care and special-
ist office visits, with a concomitant increase in
e-mail and telephonic communications between
patients and providers, resulting in operational
efficiencies while offering more patient-centric
access to providers12,13.
Costs of implementing an EMR have been
studied and analyzed. Costs are classified into
two broad categories: the direct economic cost
of the system with associated expenses, and the
costs in person-hours of implementation and
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Ciência & Saúde Coletiva, 25(4):1293-1304, 2020
use of the EMR. Implementation time is signifi-
cant, as one physician network in Texas showed14.
A practice-based information technology team
required 611 hours on average to prepare and
deploy a new EMR system. End user physicians
and other clinical team members required 134
hours, on average, per physician to prepare to use
the system in clinical encounters. The financial
cost to this group was estimated to be $162,000
for a five-physician practice, with $85,000 in
maintenance expenses during the first year. An-
other study15 showed that the economic benefit
of an EMR was 308.6% of the annual cost of the
system. A time motion study in five practices
showed that the overall time spent face-to-face
with patients after implementation of an EMR
decreased by about 30 seconds16.
Primary care providers vary in their attitudes
to the adoption of an EMR. A systematic re-
view of the world literature17 demonstrated that
younger, more computer literate primary care
physicians who are based in larger practices view
the EMR positively, compared to older physicians
who are less skilled in the use of technology and
who are based in solo practices. Factors such as
training, policies and procedures, and financial
incentives can be used to favorably influence
physician attitudes toward the EMR. Another
study from the U.S. Veterans Administration18
has similar findings.
The impact of the EMR on the physician-pa-
tient relationship has been extensively studied.
Capture of biomedical information improved
while collection of emotional and psycho-social
information was felt to be compromised. At the
same time, patient access to the information in
the EMR and reliably secure messaging functions
increased patient engagement, empowerment,
and self-management19. Physician-patient eye
contact is a critical element of communication
and a study showed that the EMR alters physician
and patient interactions with regard to gaze20.
Impact on patient satisfaction with the use of an
EMR in the examination room was found to neu-
tral to positive but the evidence for this impact
was weak21,22. One systematic review21 revealed
communication behaviors in the examination
room that were potentially beneficial (facilitat-
ing questions) and others that were potentially
negative (low rates of screen sharing, interrupt-
ed speech). Screen sharing with the patient is
one strategy that has been used to mitigate some
of the barriers. Another review23 found positive
impact on information exchange with a negative
impact on patient-centeredness, noting that the
characteristics of some physicians (behavioral
style and computer skills) overcame the negative
influences of the EMR on patient-doctor com-
munication.
A systematic review of the literature on the
use of EMRs to support population health24
identified factors that facilitate and others that
are barriers to adoption of the technology for
this purpose. Of twenty-six factors, 63% were fa-
cilitators and 37% were barriers. Factors that fa-
cilitate population health include improved pro-
ductivity and efficiency, improved quality, data
management, surveillance, and preventive care.
Factors that were deemed barriers to population
health management include missing data, lack of
standards for interoperability of different EMR
systems, loss of productivity, and overly complex
technology. The authors concluded that wider
adoption of EMRs with more comprehensive
standards for interoperability among systems
will improve the capacity to conduct surveillance
and disease management and prevention.
A meta-analysis on the impact of the EMR
on healthcare quality25 found a 22.4% reduction
in documentation time, higher adherence to
clinical guidelines, and a lower number of med-
ication errors. There was a striking reduction in
the number of adverse drug events. A study of
the pharmaceutical component of safety alert
features of EMRs in the United States26 showed
statistically significant reduction in medication
errors in patients with chronic kidney disease,
reduction in dispensing of potentially terato-
genic drugs to pregnant women, reduction of
inappropriate prescribing for geriatric patients,
reduction of co-dispensing of interacting drugs,
and a reduction of adverse drug events related to
hyperkalemia. Care processes are clearly impact-
ed by adoption of an EMR. A study of a prima-
ry care group27 showed marked improvement of
performance on quality metrics after adoption of
an EMR, a near doubling of the rate of obtain-
ing mammograms, varicella immunizations, and
glycosylated hemoglobin testing and influenza
immunization in patients with diabetes.
The EMR’s impact on a variety of health im-
provement interventions has been systematically
studied. Automated reminders and prompts to
administer the human papilloma virus vaccine
to appropriate patients performed significantly
better compared with EMRs that did not include
these features28. Changes in systems of care along
with the use of an EMR had a salutary effect on
tobacco screening and treatment rates in public
hospitals serving low income patients29, with a
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Janett RS, Yeracaris PP
significant reduction in tobacco use among pa-
tients at these hospitals. Advance care planning
to ensure that care is concordant with patients
wishes was positively impacted by the use of
tools including documentation templates, auto-
mated prompts and electronic order sets within
the EMR30. This systematic review showed more
frequent documentation of advance care plan-
ning conversations, placement of code status or-
ders, and improvement in advance care planning
outcomes.
Management of diabetes mellitus using an
EMR has been carefully evaluated. Adherence to
diabetes care standards improved 35.1 percentage
points and achievement of composite standards
for diabetes outcomes improved 15.2 percentage
points in a large study of 27,207 adults seen at
46 practices31. Thirty-eight percent of these pa-
tients were seen at ‘safety net’ facilities that treat
predominantly low-income individuals. The
availability of a patient portal to facilitate secure
electronic messaging between providers and
patients32 was associated with a significant im-
provement in patients’ glycohemoglobin levels.
A meta-synthesis of articles on diabetes care and
management using an EMR33 showed that diabe-
tes patients benefit most from decision support
tools to notify physicians of drug interactions,
communication tools to keep patients engaged
in treatment and informed of their progress, as
well as reporting and tracking tools to inform
providers of gaps in care and their performance
in closing those gaps.
In any discussion of the EMR, it is import-
ant to elucidate some of the significant draw-
backs and potential risks in adopting an EMR
system. As noted, implementation and main-
tenance costs can be high. Disruption of estab-
lished workflows and at least a transient initial
decrease in patient visit volumes and revenue are
common concerns. Electronic systems also raise
the specter of potential violations of patient con-
fidentiality and breaches of private personal in-
formation34. The failure of various EMR systems
to standardize protocols for interoperability can
impair appropriate information sharing among
providers caring for a patient. Environments
with multiple different electronic medical record
systems or with a mixture of electronic and pa-
per systems present impediments to the EMR’s
potential to improve collaboration and care co-
ordination through vertical integration4. In these
circumstances, practices often revert to scanning
of printed documents, degrading the power of
an EMR to search and compare clinical data that
would otherwise be entered into specific fields.
National and regional policies are required to es-
tablish standards for EMR interoperability.
Moreover, the proprietary nature of most
EMR systems can result in a lack of transparen-
cy that can hide coding defects within the EMR
systems themselves, which can cause systematic
errors in reportable fields and other important
elements. Specific errors related to usability have
also been documented. Complex user interfaces
make it more difficult to navigate the EMR and
can increase the likelihood of erroneous orders
for medications, testing, and other interven-
tions35. Patient safety issues in medication man-
agement have been noted when weights are en-
tered in pounds rather than kilograms, resulting
in incorrect dosing of weight-based medicines34.
Key Features and Functions of Electronic
Medical Records that Support an Integrated
Care Model
Our experience from several decades of work
are presented to illustrate ways in which the EMR
offers features and functions that support and
improve care, making it more reliable and safer
for patients.
Quality of care
Improving care quality is a challenge in all
health systems. Quality improvement is a system-
atic approach to improving care using metrics to
inform results. Quality improvement methods
are applied to many components of care, includ-
ing provider access and availability, efficiency of
patient flow, patient satisfaction, chronic disease
management, provision of preventive services,
effective use of acute care services, transitions
of care, and care coordination, among others. As
we discussed in Section I, the use of an EMR has
been shown to improve performance on a vari-
ety of quality indicators, compared to practices
that use paper records. But quality improvement
requires more than an electronic record. More
effective and reliable systems of care and work-
flows, guided by information contained in the
electronic record, are required for sustainable
performance improvement36,37. With established
standards of care and clinical protocols encoded
into the system software, reminders, checklists,
registries, patient outreach and engagement, and
reporting, the EMR supports the clinical team’s
efforts to optimize the structure, process, effi-
ciency, effectiveness, and outcome of care. Since
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Ciência & Saúde Coletiva, 25(4):1293-1304, 2020
performance measurement is an essential ele-
ment of quality improvement work, an essential
contribution of an EMR can be to streamline the
measurement and analysis of data on clinical
performance metrics, assuming that the system
is properly configured, data fields are accurately
completed, and that the software application is
sophisticated enough to support the measure-
ment and reporting process.
This is an example of ways in which an EMR
and the associated changes in the care model can
improve management of patients with type II
diabetes. First, a nationally recognized care pro-
tocol is endorsed by the provider organization,
is accepted as a care standard, and is encoded
into the EMR software. The EMR is organized
to detect patients who are overdue for specific
testing such as glycohemoglobin, nephropathy
screening, or retina examination or who have
other care interventions that are not compliant
with the care protocol. The EMR can generate a
check list of these gaps in care on any patient on
any given day. Patients who are scheduled to be
seen in the office can be offered the missing ser-
vices regardless of the reason for the visit. And
patients who are not scheduled to be seen can be
reviewed in a diabetes registry. Those with gaps
in care who do not have appointments can be
contacted by e-mail, letter, or telephone as part
of the active outreach process. These workflows,
guided by EMR based information, reliably im-
prove performance on diabetes care measures.
By embedding quality improvement work in the
daily care activities, performance improvement is
sustained over time (Chart 1).
Support for the Team-based Care Model
Team-based care is an essential component
of comprehensive integrated primary care and
a well-functioning EMR can be strategically de-
ployed to support the essential functions of the
multidisciplinary team9,38,39. High functioning
primary care practices have teams composed of
physicians, advanced practice nurses, physician
assistants, clinical pharmacists, nurse care man-
agers (for coordination of chronic disease care
and for patient education), behavioral health
specialists, social workers, nutritionists, medi-
cal assistants, nurses, receptionists and popula-
tion health managers. This care model has been
shown to improve quality of care and to increase
the capacity to care for more patients, while si-
multaneously decreasing physician workload.
Ideal staffing requires the deployment of 2 or
2.5 full-time-equivalent well-trained medical as-
sistants per full time physician38. An important
task of the medical assistant in these settings is
to assist with record keeping of the clinical en-
counter as a “scribe”, carefully documenting the
clinical encounter in the EMR, in real time, as the
physician cares for the patient38. “Scribes” have
been shown to document clinical notes that are
as accurate, or more accurate, than those of a
physician40.
With appropriate guidance and training,
medical assistants are able to perform a num-
ber of routine functions such as cancer screen-
ing, provision of preventive services, scheduling
appointments with specialists, obtaining pro-
tocol-driven lab testing, among others. These
clinical processes and pathways make care more
reliable and result in more efficient and effective
patient visits. With routine interventions man-
aged by an information-system driven protocol
that guides the activities of non-physician team
members, physicians are able to better focus on
care activities that depend on their specialized
knowledge, training and professional expertise
to establish and strengthen the patient-physi-
cian relationship38,41 and attend to the subtleties
of formulating difficult diagnoses, engaging in
shared decision making, and attending to the pa-
tient’s psycho-social needs (Chart 2).
The EMR as a tool to facilitate
communication
A high functioning EMR will support ef-
fective and efficient communication between
patients and health care providers, support hor-
izontal integration within the clinic, and sup-
port vertical integration between primary care,
specialists, hospitals, laboratories and imaging
centers.
With Patients
Patient portals support bidirectional com-
munication, offering patients easier ways to
interact with providers without the need for a
face-to-face office visit or telephone call. While
younger patients may be accustomed to e-mail
and text messaging, electronic messaging can
be more challenging to older patients. But ex-
perience is showing us that even older patients
with chronic disease are starting to use patient
portals and are enjoying enhanced access to their
provider teams. The goals of an effective patient
portal include; fostering better patient-physician
relationships, improving clinical outcomes, and
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Janett RS, Yeracaris PP
optimizing office workflows. While health sys-
tems have been slow to adopt many of the cus-
tomer-friendly electronic tools used in other sec-
tors (such as banking, travel, and on-line retail,
among others) the patient portal is an important
step in that direction.
Providers and team members can use patient
portals to efficiently communicate the results
and interpretation of diagnostic tests, inform pa-
tients of upcoming appointments and referrals,
and can answer patient questions asynchronous-
ly, without requiring that both parties be avail-
able at the same time to talk on the telephone.
Furthermore, these electronic links can help re-
mind patients of pending or overdue care inter-
ventions, such as health screenings and chronic
disease management follow up, to avoid gaps in
care. Active outreach can be simple and efficient
when patients and providers are linked electron-
ically (Chart 3).
Among members of the care team
(horizontal integration)
In order to effectively collaborate in the ef-
ficient and reliable care of patients, members of
multi-disciplinary teams must be able to easily
communicate and share information about pa-
tients. Teams engage in care planning in four
phases: before the office visit, during the visit,
after the visit, and between visits. The EMR sup-
ports the work of the multidisciplinary care team
each of these four phases. In advance of the visit,
gaps in care are identified on an EMR-generated
evidence-based-protocol-driven check list and
Chart 1. Examples of EMR and Workflows to Support Quality Improvement Activities at the Point of Care of
Patients with Diabetes Mellitus.
Quality
Improvement
Intervention
EMR
Function Workflow Example
Reduce unwarranted
variations in care
Embedded
care protocols
and clinical
practice
guidelines
Provide guidance to
all members of the
multidisciplinary team
on standards for care of
patients with diabetes
Adopt the American Diabetes Association
standards of care for adults with type II
diabetes mellitus and embed these care
standards in the EMR
Enhance reliability
of care model by
improving provider
adherence to type
II diabetes care
protocols and clinical
practice guidelines
Checklists Flag patients who present
for care and who are due
for clinical interventions.
1)A1c twice a year
2)Urine microalbumin yearly
3)Diabetic retina exam
4)Diabetic foot exams twice a year
5)Blood pressure above standard target
Registries Flag patients who are due
for clinical interventions
but who do not present
for care
Best practice
alerts
Alert multidisciplinary
team members to these
potential gaps in care
Reduce medication
errors and improve
medication
adherence in diabetes
care
Allergy lists Alert prescriber to the
presence of drug allergies
to avoid patient harm
Prior episode of angioedema due to
angiotensin converting enzyme inhibitors
Prior episodes of drug-induced
pancreatitis due to dulaglutide
Drug
interaction
functions
Alert prescriber to drug
interactions to avoid
patient harm
Potential for hypoglycemia due to co-
administration of sulfonylurea and azole
antifungal medications
Electronic
prescribing
Avoid prescription errors
due to communication
gaps between prescriber
and pharmacy
Prescriptions are transmitted directly
to the pharmacy, avoiding transcription
errors and errors in interpreting
handwriting
Improve patient adherence
to prescription regimens
Detect failure to refill prescribed
medications
Source: Elaborated by the authors.
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Ciência & Saúde Coletiva, 25(4):1293-1304, 2020
standing orders. This permits staff to offer rou-
tine required interventions to patients, allowing
those interventions to be assigned to specific staff
members and relieves the physician of the bur-
den of ordering routine interventions at the time
of the visit. During the visit, all team members
have real-time access to the patient’s medical his-
tory and other clinical information. At the end of
the visit, the EMR prints a summary of care with
instructions for the patient and informs staff
members of needed lab tests, imaging studies,
specialist consultations, and follow up visits, so
that these can be arranged in a reliable way. Care
planning between visits is supported by the EMR
registry functions, to track patients who are over-
due for preventive or disease management inter-
ventions and to guide active outreach to these
patients and to engage them in care (Chart 4).
Between primary care, specialists,
hospitals and community providers
(vertical integration)
Transfer of responsibility for care of a patient,
during transitions of care, is a time of high risk.
It is estimated that 80% of serious medical er-
rors result from miscommunication during these
hand-offs42. Better bidirectional communication
between primary care physicians, specialists, and
Chart 2. Examples of Workflows Supported by a Multi-Disciplinary Team and an EMR.
Workflow Example EMR Function
Close gaps in care identified during the pre-visit planning process:
Checklist, registries, embedded
clinical protocols, and standing
orders
1) Health screening and
preventive care interventions
Occult blood testing for colon
cancer screening, scheduling
mammography, administer
behavioral health screens (PHQ9,
SBIRT, GAD7, etc.)
2) Chronic disease
management and testing
Point of care
A1C testing, scheduling diabetic
eye exam
3) Alert the physician of
needed interventions
Blood pressure measured noted
to be higher than target, remove
shoes for diabetic foot exam
Medication reconciliation Reconcile medication list with
patient and family
Medication and allergy lists
“Scribe” functions Document patient history,
physical examination, assessment,
diagnosis, and plan at the time of
the visit
Templates, reportable fields,
diagnosis look-up tables
Reliably performing all clinical
interventions ordered at the visit
Scheduling specialist consults,
scheduling follow up visits,
ordering non-routine imaging
studies and labs
Team communication protocols
through secure messaging, routing
sheet, after-visit summary
Avoiding gaps in care during the between-visit planning process:
1) Identify patients who have
not visited the health unit in the
desired timeframe
Contact patients and engage them
in follow up care
Patient registries, links to the
scheduling module to find patients
who do not have upcoming
appointments
2) Identify patients who
require advanced support for chronic
conditions or because of frailty
Medical and behavioral health
case management services, social
work outreach
Patient registries, risk stratification
module
3) Identify patients who have
poorly controlled disease indicators
Identify and outreach to patients
with hyperglycemia, uncontrolled
hypertension, or who are overdue
for follow up on abnormal test
results
Patient registries, links to lab data
and imaging data modules, patient-
generating home monitoring data
Source: Elaborated by the authors.
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Janett RS, Yeracaris PP
hospitals during times of transitions of care is
supported by an EMR’s secure messaging func-
tions and by the ability of providers to seamless-
ly forward clinical information to one another.
This is accomplished either with a common re-
cord shared by all members of an integrated care
system or by using health information exchange
protocols to link disparate records systems. Shar-
ing information, communicating ideas and ad-
vice, and organizing referrals and appointments
from primary care to other providers and from
those providers back to primary care promotes
collegiality, confidence, and collaboration be-
tween primary care and specialists (Chart 3).
Effective management of transitions of care
requires more than just good communication.
Chart 3. Essential features of a high functioning patient portal, best communication practices for vertical
integration, best practices for medication management, best practices with regard to checklists.
1—Essential features of a high functioning patient portal
· Sending messages to and receiving information from the care team
· Allowing patient to schedule appointments online
· Viewing medications and making prescription refill requests
· Viewing bills and making payments
· Viewing and updating health information
· Filling out forms in advance of the visit
2—Best communication practices for vertical integration:
· Important information is readily visible and easily to understand.
· An effective note from a primary care physician to a specialist or a hospital has the reason for referral,
pertinent history, physical findings, and relevant test results.
· Specialist recommendations and conclusions are highlighted in the report back to the primary care doctor.
· Hospital discharge communications detail the final diagnoses, test results, medication changes, and timing of
appropriate follow up care.
3—Best practices for medication management
· Assiduous attention to medication reconciliation at every encounter
· Share of current medication list with every provider
· Use of drug-drug interaction software
· Automated cross referencing of allergies and prescriptions
· Electronic prescribing
· Including cost and insurance-coverage information to inform cost-effective prescribing
4—Best practices with regard to checklists include:
· Information shared by and accessible to all members of clinical multidisciplinary team
· Automated updating and refreshing of data by the EMR, minimizing the need for manual updates of data fields
· Flexibility to vary the targeted time interval between interventions ( For example: Follow up CT scan of a
pulmonary nodule at 3 months, six months, or one year. Follow up of a mammogram at 6 months, one year, or
two years )
· Flexibility to mark certain interventions as ‘not consistent with goals of care’ ( For example, to stop colon
cancer screening in patients with life expectancy of less than ten years )
Update the checklist specifications periodically as evidence-based clinical guidelines change over time
Source: Elaborated by the authors.
It also involves coordination, standardization of
work processes, training, and accountability43.
Responsibilities of the referring physician and
the receiving physician must be established in
advance of the transfer.
Medication Management within the EMR
Medication errors represent a major threat
to patient safety in ambulatory practice, con-
tributing to an estimated 1 out of 131 outpa-
tient deaths per year in the United States36. The
electronic record offers unsurpassed tools to
improve accuracy and efficiency in medication
management. Medication lists can be automat-
ically updated with each new prescription and
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Ciência & Saúde Coletiva, 25(4):1293-1304, 2020
Chart 4. Four Phases of Care Planning Supported by an EMR.
Planning
Phase
EMR Function Workflow Example
Pre-visit Checklist Assign task to specific team members
before the patient arrives in the office
Multidisciplinary team
huddles before the clinical
session to identify patients
who are overdue for
preventive services or
chronic disease management
interventions
During the
visit
Checklist
Medication List
Immunization List
Administer screening tests immunizations,
and chronic disease management testing
and treatment. Medication reconciliation
Reliably provide necessary
services at the time of the
encounter
After the
visit
Electronic order
entry
Referral
management
module
After visit summary
Schedule specialist appointments and
ancillary testing.
Draw labs ordered at the visit.
Schedule follow up appointment.
Review prescriptions and follow up care
with patient.
Reliably complete all tasks
ordered at the visit.
Assure that the patient
understands follow-up plan.
Between
visits
Registries Identify and contact patients who have not
followed up at the appropriate interval.
Identify patients with clinical parameters
that are outside of established goals, i.e.
blood pressure or glycemic control above
targeted values.
Detect patients who have gaps
in care and are not scheduled
for follow up.
Active outreach to those
patients.
Source: Elaborated by the authors.
rigorous attention to reconciling the medica-
tions that the patient is actually using with the
medication list helps to avoid omission of essen-
tial medication or the prescription of duplicate
medication. Sharing of medication lists among
all providers who treat the patient helps to im-
prove vertical integration and care coordination.
Automated drug-drug interaction software helps
to reduce unintentional prescriptions of drugs
with adverse interactions. In some EMR systems,
the cost and insurance-coverage of drugs is avail-
able to the physician at the point of care, allow-
ing for more cost-effective choices of drugs. Very
sophisticated electronic prescribing systems link
prescribers and pharmacies, eliminating the need
for paper prescriptions and thereby improving
accuracy and efficiency in the prescribing and the
drug dispensing processes (Chart 3).
Use of EMR-generated care checklists
An essential feature of the EMR, and one
that improves the reliable delivery of services at
the point of care, is the EMR-generated check
list. The EMR produces a list of patient care
interventions that should be provided at the
visit. These interventions include vaccinations,
screening procedures such as fecal occult blood
tests or pap smears, mammography, depression
screening, diabetes metabolic labs, follow up on
abnormal imaging studies, and other interven-
tions governed by the standards established in
evidence-based care protocols. All members of
the multidisciplinary team have access to this
checklist. Needed interventions can be assigned
to team members before the patient arrives at the
office for a visit. Using standing orders, non-phy-
sician staff have the authority to obtain lab tests,
schedule appointments with specialists, and per-
form other routine interventions
Use of Registries to Guide Active Outreach
to Patients with Gaps in Care
It is always a challenge to engage some sub-
sets of patients in appropriate follow up care. Pa-
tients commonly fail to schedule or do not keep
follow up appointments and gaps in care result
when patients do not present for necessary health
services. Health systems are constantly trying to
improve their performance on rates of cancer
screening, vaccinations, and other preventive ser-
1302
Janett RS, Yeracaris PP
vices, and improve their management of chron-
ic disease (such as glycemic and blood pressure
control in diabetes, follow up of abnormal test
results, and adherence to the use of controller
inhaler medications in asthma). The EMR offers
tools, in the form of patient registries, to identify
patients who do not present themselves for care
but who have unmet care needs.
The registry function in many EMR systems
has been slow to evolve. Flexibility in creating
new registries or modifying fields and decision
support rules are important functionalities. For
example, being able to enter a due date for a fol-
low up colonoscopy based on latest examination
or biopsy results or being able to track and sort
patient depressions screening/PHQ 9 scores to
ensure appropriate outreach and follow up, can
help systematize and streamline efforts to im-
prove care.
Conclusion
There is strong evidence for the benefits of an
EMR in terms of efficiency, reliability, and care
quality, especially in primary care. Some of these
benefits are counterbalanced by clearly defined
risks and drawbacks of EMR systems. Key features
of EMR systems have been identified as facilita-
tors of or barriers to effective implementation
and use of these systems to support population
health, chronic disease management, the reliable
delivery of preventive services, and improved
patient safety through the avoidance of medical
errors, especially with regard to pharmaceuticals.
Effective use of the technology requires care-
ful attention to workflows, teamwork, and other
key clinical practice reforms. The best way to take
advantage of the EMR’s advanced functionalities
is to deploy a multidisciplinary team in a com-
prehensive care model. The EMR is unsurpassed
as a tool to enhance communication among
members of the care team and between providers
at various levels of care, supporting horizontal
and vertical integration. To maximize the effec-
tiveness of the new capabilities, cultural changes
at the practice and system level are necessary to
support behavior norms, compacts, and mutual
expectations among providers on collaboration
in the care of patients.
There are many reasons why the EMR has yet
to live up to its full potential and it is important
to learn the lessons from past and current efforts
in order to ensure the most effective design and
implementation of an EMR system. Important
functionalities such as modifiable check lists and
registries, the ability to easily design and run re-
ports, user friendly provider interfaces and a sim-
ple and easily accessible patient portal contribute
to effective use of the EMR’s complex capabilities.
The United States has seen the deployment
of a variety of EMR systems with various degrees
of sophistication. Considerable problems have
been noted due to a lack of interoperability and
standardization of interfaces among these sys-
tems, impairing the effective collaboration and
information exchange in the care of complex pa-
tients. It is extremely important that regional and
national health policies be established to assure
standardization and interoperability of systems.
Vendors of EMR systems have engaged in exten-
sive lobbying and marketing efforts to advance
the commercial and proprietary interests of their
companies. These efforts contribute to the frag-
mentation of the information environment.
The EMR is a disruptive technology that can
revolutionize the way we care for are patients.
The key lessons from the US experience in the
deployment and use of these systems are (1) at-
tention to interoperability among various sys-
tems, and (2) careful attention to the impact of
the EMR on clinical workflows, in order to take
full advantage of the potential of the EMR to im-
prove patient care.
1303
Ciência & Saúde Coletiva, 25(4):1293-1304, 2020
References
1. Dick RE. The Computer-Based Patient Record. Wash-
ington: National Academies Press; 1997.
2. National Coordinator for Health Information Tech-
nology (ONC). HealthIT.gov. (2017, October 5).
Health IT and Health Information Exchange Basics.
[cited Sept 10, 2019]. Available from: https://www.
healthit.gov/topic/health-it-basics/benefits-ehrs
3. Hillestad RE, Bigelow J, Bower A, Girosi F, Meili R,
Scoville R, Taylor R. Can Electronic Medical Record
Systems Transform Health Care? Potential Health
Benefits, Savings, and Costs. Health Affairs 2005;
24(5):1103-1117.
4. Schulte F, Frye E. Death by a Thousand Clicks. Fortune
2019; Mar 18.
5. Gorn D. These doctors think electronic records are
hurting their relationships with patients. 2017, July 21.
[cited Sept 10, 2019]. Available from: https://www.
pbs.org/newshour/health/doctors-think-electron-
ic-health-records-hurting-relationships-patients
6. Peikes DE. Independent Evaluation of Comprehensive
Primary Care Plus (CPC+). Princeton: Mathematics
Policy Research; 2019.
7. World Health Organization (WHO). WHO Frame-
work on Integrated Person Centered Health Services.
Geneva: WHO; 2019. [cited Sept 10, 2019]. Available
from: https://www.who.int/servicedeliverysafety/ar-
eas/people-centred-care/en/
8. American Academy of Family Physicians, American
Academy of Pediatrics, American College of Phy-
sicians, American Osteopathic Association. (2017,
March). Joint Principles of the Patient Centered Medi-
cal Home. [cited Sept 10, 2019]. Available from: http://
www.aafp.org/dam/AAFP/documents/practice man-
agement/pcmh/initiatives/PCMHJoint.pdf
9. Wagner ECK. Guiding Transformation: How Medical
Practices Can Become Patient Centered Medical Homes.
New York: The Commonwealth Fund; 2012.
10. Holroyd-Leduc JL, Straus S, Sykes L, Quan H. The
impact of the electronic medical record on structure,
process, and outcomes within primary care: a system-
atic review of the evidence. J Am Med Inform Assoc
2011; 18(6):732-737.
11. Kemper A., Uren R, Clark S. Adoption of electronic
health records in primary care pediatric practices. Pe-
diatrics 2006; 118(1):e20-24.
12. Chen C, Garrido T, Chock D, Okawa G, Liang L. The
Kaiser Permanente Electronic Health Record: trans-
forming and streamlining modalities of care. Health
Aff (Millwood) 2009; 28(2):323-333.
13. Zhou Y, Garrido T, Chin H, Wiesenthal A, Liang L. Pa-
tient access to an electronic health record with secure
messaging: impact on primary care utilization. Am J
Manag Care 2007; 13(7):418-424.
14. Fleming N, Culler S, McCorkle R, Becker E, Ballard D.
The financial and nonfinancial costs of implementing
electronic health records in primary care practices.
Health Aff (Millwood) 2011; 30(3):481-489.
15. Gallego A, Gagnon M, Desmartis M. Assessing the
cost of electronic health records: a review of cost indi-
cators. Telemed J E Health 2010; 16(9):963-972.
16. Pizziferri L, Kittler AF, Volk LA, Honour MM, Gup-
ta S, Wang S, Wang T, Lippincott M, Li Q, Bates DW.
Primary care physician time utilization before and af-
ter implementation of an electronic health record: a
time-motion study. J Biomed Inform 2005; 38(3):176-
188.
Collaborations
RS Janett and PP Yeracaris collaborated exten-
sively in the writing of this paper and it was a true
joint effort. RS Janett took primary responsibility
for the evidence review, the quality section, the
medication management section, and the devel-
opment of the figures. PP Yeracaris took prima-
ry responsibility for the sections on team based
care, facilitating communication among team
members, with specialists, with patients and the
use of registries to address gaps in care.
1304
Janett RS, Yeracaris PP
17. O’Donnell A, Kaner E, Shaw C, Haighton C. Primary
care physicians’ attitudes to the adoption of electron-
ic medical records: a systematic review and evidence
synthesis using the clinical adoption framework. BMC
Med Inform Decis Mak 2018 13; 18(1):101.
18. Saleem JJ, Flanagan ME, Russ AL, McMullen CK, Elli
L, Russell SA, Bennett KJ, Matthias MS, Rehman SU,
Schwartz MD, Frankel RM. You and me and the com-
puter makes three: variations in exam room use of the
electronic health record. J Am Med Inform Assoc 2014;
21(e1):e147-151.
19. Rathert C, Mittler J, Banerjee S, McDaniel J. Pa-
tient-centered communication in the era of electronic
health records: What does the evidence say? Patient
Educ Couns 2017; 100(1):50-64.
20. Montague E, Asan O. Dynamic modeling of patient
and physician eye gaze to understand the effects of
electronic health records on doctor-patient com-
munication and attention. Int J Med Inform 2014;
83(3):225-234.
21. Alkureishi MA, Lee WW, Lyons M, Press VG, Imam S,
Nkansah-Amankra A, Werner D, Arora VM. Impact
of Electronic Medical Record Use on the Patient-Doc-
tor Relationship and Communication: A Systematic
Rev iew. J Gen Intern Med 2016; 31(5):548-560.
22. Irani JS, Middleton JL, Marfatia R, Omana ET, D’Am-
ico F. The use of electronic health records in the exam
room and patient satisfaction: a systematic review. J
Am Board Fam Med 2009; 22(5):553-562.
23. Shachak A, Reis S. The impact of electronic medical
records on patient-doctor communication during
consultation: a narrative literature review. J Eval Clin
Pract 2009; 15(4):641-649.
24. Kruse C, Stein A, Thomas H, Kaur H. The use of Elec-
tronic Health Records to Support Population Health:
A Systematic Review of the Literature. J Med Syst
2018; 42(11):214.
25. Campanella P, Lovato F, Marone C, Fallacara L, Rioc-
ciardi W, Specchia M. The impact of electronic health
records on healthcare quality: a systematic review and
meta-analysis. Eur J Public Health 2016; 26(1):60-64.
26. Ojeleye O, Avery A, Gupta V, Boyd M. The evidence
for the effectiveness of safety alerts in electronic pa-
tient medication records systems at the point of phar-
macy order entry: a systematic review. BMC Med In-
form Decis Mak 2013; 13:69.
27. Gill J, Ewen E, Nsereko M. Impact of an electronic
medical record on quality of care in a primary care
office. Del Med J 2001; 73(5):187-194.
28. Ruffin M, Plegue M, Young A, Patel D, Yeazel M. Im-
pact of an Electronic Health Record (EHR) Reminder
on Human Papillomavirus (HPV) Vaccine Initiation
and Timely Completion. J Am Board Fam Med 2015;
28(3):324-333.
29. Moody-Thomas S, Nasuti L, Yi Y, Celestin MD Jr,
Horswell R, Land TG. Effect of systems change and
use of electronic health records on quit rates among
tobacco users in a public hospital system. Am J Public
Health 2015; 105(Supl. 2:e1-7).
30. Huber M, Highland J, Krshnamoorthi V, Tang J. Uti-
lizing the Electronic Health Record to Improve Ad-
vance Care Planning: A Systematic Review. Am J Hosp
Palliat Care 2018; 35(3):532-541.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License
BY
CC
31. Cebul R, Love T, Jain A, Hebert C. Electronic health
records and quality of diabetes care. N Engl J Med
2011; 365(24):2338-2339.
32. Kuo A, Dang S. Secure Messaging in Electronic Health
Records and its Impact on Diabetes Clinical Out-
comes: A Systematic Review. Telemed J E Health 2016;
22(9):769-777.
33. Lessing SE, Hayman LL. Diabetes Care and Manage-
ment Using Electronic Medical Records: A Systematic
Rev iew. J Diabetes Sci Technol 2019; 13(4):774-782.
34. Menachem N, Collum T. Benefits and drawbacks of
electronic health systems. Risk Manag Healthc Policy
2011; 4:47-55.
35. Howe J, Adams K, Hettinger A, Ratwani R. Electronic
Health Record Usability Issues and Potential Contri-
bution to Patient Harm. JAMA 2018; 319(12):1276-
1278.
36. Agency for Healthcare Research and Quality (AHRQ).
Patient Safety Primer--Ambulatory Care Safety. (2019,
January). [cited Sept 10, 2019]. Available from: https://
psnet.ahrq.gov/primers/primer/16/patient-safe-
ty-in-ambulatory-care
37. American College of Physicians. Patient Safety in the
Office-Based Practice Setting. Philadelphia: American
College of Physicians; 2017.
38. Sinsky C, Bodenheimer T. Powering-Up Primary Care
Teams: Advanced Team Care with in-room support.
Annals of Family Medicine; 2019.
39. Bodenheimer T. Building Powerful Primary Care
Teams. Mayo Clin Proc 2019; 94(7):1135-1137.
40. Misra-Herbert A, Amah L, Rabovsky A, Morrison S,
Cantave M, Hu B, Rothberg M. Medical scribes: How
do their notes stack up? J Fam Pract 2016; 65(3):155-
159.
41. Anderson P, Halley M. A New Approach to Making
Your Doctor-Nurse Team More Productive. Fam Pract
Manag 2008; 15(7):35-40.
42. Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost
in translation: challenge and opportunities in phy-
sician-to-physician communication during patient
hand-offs. Acad Med 2005; 80(12):1094-1099.
43. The Joint Commission. (2018, January). Transitions
of Care: The need for a more effective approach to con-
tinuing patient care. [cited Sept 10, 2019]. Available
from: https://www.jointcommission.org/assets/1/18/
Hot_Topics_Transitions_of_Care.pdf
Article submitted on 02/10/2019
Approved on 20/10/2019
Final version submitted on 22/10/2019
