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April 4, 2001

Electronic Medical Records: A Decade of Experience

Author Affiliations

Chief Executive Officer, Clinician Support Technology, Framingham, Mass and Harvard Medical School, Boston, Mass

Chief Executive Officer, Clinician Support Technology, Framingham, Mass and Harvard Medical School, Boston, Mass

JAMA. 2001;285(13):1766. doi:10.1001/jama.285.13.1766-JMS0404-4-1

My colleagues and I originally built an electronic patient record at the Beth Israel Deaconess Medical Center (BIDMC) in 1989 simply to facilitate sharing of information over geographically dispersed practice locations.1 However, the introduction of an electronic patient record has fundamentally changed the practice of medicine in ways that we never foresaw. This type of highly interactive program tailored to medical workflow improves the quality of care,2 reduces medication errors,2 saves physician and nurse time,3 improves resident and medical student clinical precepting,4 and supports collaboration in complex organizations.5

While the electronic patient record seems to be the holy grail of clinical computing, the idea is straightforward: take the physician's paper chart and make it electronic. Of course, since paper records are not standardized neither are electronic records. An informal count finds more than 400 companies that claim to have such programs for physicians. Any implementation of an electronic medical record requires certain decisions about how medicine is practiced, and making such a system work is not as simple as taking a paper chart and making it electronic. For instance, can 2 people in the same office look at a patient's chart at the same time? Is the physician part of a health system that needs to share patient records more broadly? How well can the data collected by the system support quality improvement with alerts or reminders? How do the data get into the record?

BIDMC is served by the Center for Clinical Computing (CCC) system, a mature system that began to evolve in the late 1970s to support the clinical information needs of staff and the administrative needs of the hospital.6 This system is now one of the most widely used in the United States. Physicians use the computing system to look up the results of all diagnostic studies, to send and receive electronic mail, and to perform a variety of decision support tasks, including online literature searching, computer-assisted expert consultation, and online clinical calculation.

As a part of this heavily used CCC system, in 1989 colleagues and I at the CCC developed an extensive online medical record (OMR) for use in an ambulatory primary care practice with the goals of facilitating workflow, supporting collaborative practice models, delivering clinical practice guidelines, and making the ambulatory office paperless. Clinicians interact directly with the computer system, increasing the accuracy of data capture and providing an opportunity for education, documentation, and action.

Since the system was first introduced, more than 1000 different staff physicians, nurses, resident physicians, and psychiatric social workers have entered 1 278 484 progress notes and 391 897 medical problems and written online 1 367 450 prescriptions for more than 53 000 patients.3 Clinicians have also documented health promotion and disease prevention tasks, such as recording a patient's blood pressure. Confidence in the well-published security measures is so great that even psychiatric notes are kept online.7

With such a heavily used system in place, we had the opportunity to change medical practice as McDonald8 and others have done. We developed computer programs to alert the clinician about clinical events, to help the clinician to act on the information, and to document the clinician's response in the medical record. A nonrandomized, controlled, prospective trial performed during an 18-month period found that the presentation of a set of alerts and reminders as part of computer-based medical record resulted in significantly faster and more complete adoption of practice guidelines by a group of clinicians treating patients with human immunodeficiency virus infection.2

With fully functioning electronic patient record systems to monitor care, computers can perform many care coordination and documentation functions, freeing people to concentrate more on interpersonal interactions and provision of health care services.4,5 With shared electronic patient records, busy health care providers can collaborate and asynchronously update plans and progress; for instance, several specialists participating in the care of a patient can share medication lists, exchange notes, and alert each other to problems.

The promise of the electronic patient record is real and proven, but the reality for physicians in the United States has been largely unrealized. Perhaps the emerging generations of physicians with computer skills and consumers of health care who demand digitally ensured quality will spur adoption of a technology that saves lives and improves the quality of care.

Financial Disclosure: Dr Safran has an equity interest in Clinician Support Technology, an e-health application service provider.
Safran  CRury  CRind  DTaylor  WC A computer-based outpatient medical record for a teaching hospital.  MD Comput. 1991;8291- 299
Safran  CRind  DMDavis  RB  et al.  Guidelines for the management of HIV infection in a computer-based medical record.  Lancet. 1995;346341- 346Crossref
Safran  CSands  DZRind  DM Online medical records: a decade of experience.  Method Inf Med. 1999;38308- 312
Patel  VLCytryn  KNShortliffe  EHSafran  C The collaborative health care team.  Teaching Learning Med. 2000;12117- 132Crossref
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Bleich  HLBeckley  RFHorowitz  GL  et al.  Clinical computing in a teaching hospital.  N Engl J Med. 1985;312756- 764Crossref
Safran  CRind  DCitroen  MBakker  ARSlack  WVBleich  HL Protection of confidentiality in the computer-based patient record.  MD Comput. 1995;12187- 192
McDonald  CJ Protocol-based computer reminders, the quality of care, and the non-perfectibility of man.  N Engl J Med. 1976;2951351- 1355Crossref