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April 4, 2001

Patient Participation in Electronic Medical Records

Author Affiliations

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JAMA. 2001;285(13):1765. doi:10.1001/jama.285.13.1765-JMS0404-3-1

Electronic medical records (EMRs) hold great promise for improving the practice of medicine by facilitating communication between members of the health care team. The most profound influence of EMRs may lie in their ability to encourage patients' involvement in their own care. Potentially, patients could use EMRs to access their medical records online, learn about their health conditions, communicate with physicians, and even contribute to the chart itself. Certain hurdles to such access have yet to be overcome, such as ensuring privacy of personal medical data and determining the ways in which patients should be able to influence their charts; once these challenges are met, patients can look forward to a future of increased participation in and control over their own care.

Prior innovations in telemedicine provide the foundation for interactive EMR projects. Telemedicine uses remote transmission of video, audio, and text data to provide subspecialist care or consultation to patients who might not otherwise have access to it. In teleradiology, for example, a neuroradiologist working remotely can diagnose brain pathology by looking at a digital image.1 Telemedicine can also facilitate the practice of cardiology, orthopedics, dermatology, and psychiatry.2 Telemedicine has been used to provide medical care to underserved rural communities, disaster areas, and military operations.3

Interactive EMR builds on the telemedicine framework by making the medical chart, traditionally the province of the health care provider, a shared document that patients can access and update themselves. Numerous projects already allow patients to read specified portions of their charts online, manually enter data, and verify their medication dosages or track what doses they have taken. The Patient Clinical Information System (PATCIS) project provides patients with the ability to view laboratory results and text reports through a Web interface and to enter data such as vital signs.4 The Patient Centered Access to Secure Systems Online (PCASSO) project focuses on developing a robust security architecture for direct patient access to an EMR.5

The largest project combining telemedicine with patient access to an EMR is the Informatics for Diabetes Education And Telemedicine project (IDEATel).6 Begun in February 2000, the IDEATel project is a 4-year, $28-million randomized clinical trial designed to maximize Medicare patients' control of their diabetes by providing them with a computerized link to their caregivers. Patients use a home telemedicine unit (HTU) that allows them to interact in multiple ways with their online charts. When patients measure blood pressure or fingerstick glucose with devices connected directly to the HTU, the results are automatically encrypted and transmitted securely over the Internet into the Columbia University Web-based Clinical Information System (WebCIS) and to customized case management software. Patients can also view and enter other data including diet, medication, and exercise information through the EMR. Patients and diabetes case managers can communicate through a secure clinical email system as well as via videoconferencing; case managers also receive alerts when patients' transmitted values exceed set thresholds. By allowing direct patient interaction with the EMR, case managers and physicians have much more accurate and up-to-date information for managing therapy. Patients learn to monitor their own condition by receiving immediate feedback after finger sticks and comparing blood glucose values over time.

No new health care technique will be implemented unless it is demonstrated to be cost-effective, whether by improving health outcomes, or decreasing costs, or both.7 Several studies have suggested that telemedicine is able to decrease costs while maintaining quality in the management of congestive heart failure, chronic obstructive pulmonary disease, cerebral vascular accident, cancer, diabetes, and anxiety.8

Patient interaction with EMRs has the potential to reduce the frequency of clinical visits and improve health outcomes. Yet, one concern is that telemedicine interactions will replace clinical encounters, thus deteriorating the patient-physician relationship. It remains to be seen whether the face-to-face clinical encounters that supplement interactive EMR will be more productive and satisfying because of the long-term connection between physician and patient that can be provided by the EMR system.

As telemedicine becomes incorporated into chronic disease management across the United States, patient-oriented EMRs may become a part of the standard of care of outpatient management in all medical specialties. Soon, third-year clerks may spend part of their ambulatory care rotation videoconferencing with patients and reviewing EMRs with them remotely.

Allen  APatterson  JD Annual survey: teleradiology service providers.  Telemed Today. 1997;524- 25
Not Available, Abt Associates' national survey of rural telemedicine.  Department of Commerce, Telemedicine Report to the Congress 16 January13 1997;
Garshnek  MSBurkle  JR Applications of telemedicine and telecommunications to disaster medicine: historical and future perspectives.  J Am Med Inf Assoc. 1999;626- 37Article
Cimino  J Patient access to clinical information: the PatCIS project.  Dec31 2000; National Library of Medicine Final Report, National Information Infrastructure Contract N01-LM-6-3542
Baker  DBMasys  DR Assurance: the power behind PCASSO security.  J Am Med Inf Assoc. 1999;6fall (symp suppl) 666- 670
Not Available, Informatics for Diabetes Education and Telemedicine (IDEATel) home page. Available at: www.ideatel.com. Accessed January 31, 2001
Masys  DR Telehealth: The need for evaluation.  J Am Med Inf Assoc. 1997;469- 70Article
Johnston  BWheeler  LDeuser  JSousa  K Outcomes of the Kaiser Permanente tele-home health research project.  Arch Fam Med. 2000;940- 45Article