The electronic medical record (EMR) was designed to ease data collection, access, and provide widened transparency across various physicians to help improve the quality and safety of healthcare.  Its implementation into our daily clinic and hospital settings is thought to be a vital element to the revolution of the US healthcare system and the PCMH by improving efficiency, accuracy, and safety [1].  The (EMR) is touted to bridge the gap between patients and their physicians by allowing faster more efficient modes of communication and consolidation of medical information.  While there are benefits to the EMR, there are also significant negatives.

 
2. Clear Benefits

While the utility of the EMR can be debated there are some clear benefits that are hard to argue with.  First of all, there is better legibility using an EMR than hand-written documents including notes, orders, problem lists, and medications.  Secondly, the EMR is able to hold more data than a paper chart and without the use of actual office space. 
 
3. Productivity Effects

While many erroneously thought implementation of the EMR would improve productivity and efficiency, it does not appear to be the case at most institutions.  It is often noted that EMR implementation reduces productivity, but it was thought this reduced productivity would improve over time as providers became more skilled using the EMR.  In a qualitative analysis of EMR implementation at Kaiser, however, this reduction in productivity did not appear to dissipate over time [2].
 
4. Too much information

The quality of healthcare delivered is largely dependent on the integrity, accountability, and accuracy of health information [3].  While the EMR provides and captures plentiful information, it can leads to inefficiency and confusion if the data displayed is not comprehended in the right context, presented in a complex manner, or difficult and time consuming to reference.   Another problem is that so much information is being collected that the attention to detail in obtaining and reviewing the information can be reduced as nurses and providers rush to complete all of the required data fields.  Deficiencies in the EMR based upon its design and implementation has led to poor documentation, inaccurate data, and inadequate communication [4,5]. This causes errors, adverse incidents, and compromises patient safety.  Furthermore, this domino effect not only affects the financial sustainability of hospital corporations but insufficient data collection deters the progress of clinical research, performance improvement, and quality measurement initiatives [3].  A pilot study evaluating information accuracy in the electronic health record, led by Tse and You, showed that inaccuracies in medication lists were reported in 51% of the records reviewed with 32.1% of all medications being inaccurately recorded [6]. 
The EMR has been noted to generate various kinds of systems use errors. Instead of leading to improvements in the quality of data being recorded, it has led to generating a greater quantity of bad data [7-9]. Inappropriate documentation capture through the function of copy and paste is the perfect example to demonstrate this. While its main role was meant to ease accessing and placing data from previous encounters into the most recent encounter, it has instead led to production of an overbearingly long and verbose, inaccurate and non-relevant accumulation of data, making the documentation difficult to sort through. This technique creates for outdated and redundant information, causing inability to identify the most current and valuable information, difficulty in identifying the intent of documentation or most recent visit, possible circulation of false information which can lead to allegations of fraud, and inconsistent and unnecessarily lengthy notes [10]. In its defense, the copy and paste function when used properly, improves the efficiency of data capture, timeliness and legibility of the document, and potential accuracy of data. The responsibility of minimizing the errors associated with inappropriate documentation capture falls heavily onto the provider who must be vigilant in choosing his or her information carefully when generating a new note.

 
5. Patient Portals

By means of the portal system, patients can access their medical information hours after their encounter and can correspond with queries to their physicians through e-messaging, allowing for a direct online relationship to be cultivated.  However, confusion can be experienced by the patient without a medical background who strives to make sense of the large amount of medical information they have access to.
 
6. Patient Physician Communication

For better or worse, the EMR has significantly altered patient-physician communication.  Studies show that eye contact is decreased after EMR implementation, and this can have a negative impact on a patient-physician relationship [11].

As we enter the age of transparency and push to upgrade our office gadgets to the newest version of technology and data capture techniques, we must keep in mind the ways in which data is being collected, depicted, and interpreted to ensure that data accuracy and information integrity is not compromised.  We must also question how accurate the information displayed in the EMR truly is.
 
7. Does the EMR Improve Patient Safety?

A major deficiency of the EMR is the lack of regulatory framework to monitor its system safety when errors are made, lending itself to propagating data inaccuracy. The systems may have been developed from incomplete design specifications, be dependent on unreliable hardware or software platforms, have programming errors or bugs, may work well in one context or organization but be unsafe in another, and change how clinicians do their daily work, thereby introducing new potential failure modes [7,12].  While the goal of employing EMR is to reduce medical errors, new types of errors specifically related to its use are made frequently. In one example, a patient’s treatment of cancer was compromised and delayed by many years due to a setting in her physician’s EMR system which defaulted to an old normal Pap test rather than the most recent abnormal results [13]. Mistakes have occurred due to entering of inaccurate medication dosages into the EMR, not only causing patients to suffer from serious side effects but also placing their lives in danger. This can be avoided if specific automated alerts were to be activated when inappropriate doses of medications are entered.   Most EMRs also cannot check for medication-diagnosis interactions.  We had an incident at my clinic where Levaquin was prescribed to a patient with myasthenia gravis, but is contraindicated for patients with this condition.  The EMR, however, was unable to identify this problem.   
As technology continues to grow at a rapid pace, health information technology must be upgraded to give physicians the best chance of providing quality care in an efficient and safe manner. Do appropriate tracking measures exist for capturing errors when they occur? The answer is no. Currently, there are no regulatory requirements in place to evaluate the EMR system efficacy and safety, and as a result, no method exists to adequately fix these errors in a systematic forum [14].  In the online article from Scientific American titled ‘Why We Must Keep Track of Errors in Electronic Medical Records’, author Michael Glenwood proposes the creation of a national safety board to collect data on e-record errors so that this information can be used to issue guidelines in the medical industry [15]. The initiation of Medical Event Reporting in certain states is a step towards identifying when mistakes are made so they can be prevented and rectified from the human perspective. Insight into reasons for the errors may also allow for the upgrade and improvisation of software databases, leading to safer data capture and improved data accuracy.  

Physicians strive hard to care for their patients and rely heavily on the EMR to provide a fluid space in which to capture relevant data. This data is then viewed and analyzed by future providers and that patient, after which medical decision making occurs for the well-being of the individual. The EMR has certainly solved problems encountered with paper charts such as deciphering illegible medical handwriting and making information available in an easy workspace. However, it has also generated its own flaws, some which are systems based while others are operator-dependent. Studies have demonstrated that widespread transparency and access of information generated through EMR has not necessarily resulted in greater accuracy of data, but instead led to errors in medication doses, providing inaccurate preventative screening measures, and missing most relevant medical history components, hence serving as a double edged sword. Lack of regulatory measures to identify and appropriately address medical errors may reduce the incentives for leadership and outpatient based practices to invest money into the latest EMR software. Solutions to these problems include reporting of medical errors to a widespread Federal committee focused on identifying reasons for the errors and providing guidelines and improvisations in the software database to minimize them. Meanwhile, physicians must caution themselves that more access and availability of data through EMR does not translate to greater accuracy of the information.  They must use this information carefully when seeking to provide quality care. 

1. JM Sullivan (2007) Recent Developments and Future Trends in Electronic Medical and Personal Health Records. 19: 3.

2. Scott T, Rundall T, Vogt T, Hsu J (2005) Kaiser Permanente’s experience of implementing an electronic medical record: a qualitative study.  BMJ 331.

3. American Health Information Management Association (AHIMA) (2012) Data Quality Management Model. Chicago, IL.

4. Kohn, Linda T, Janet M Corrigan, Molla S (2000) To Err is Human: Building a Safer Health System 312.

5. Kellermann Arthur L, Jones Spencer S (2013) What It Will Take To Achieve The As-Yet-Unfulfilled Promises of Health Information Technology. Health Affairs 32:63-68.  

6. Tse J, You W (2011) how accurate is the electronic health record? - A pilot study evaluating information accuracy in a primary care setting. Stud Health Technol Inform 168: 158-164.  

7. Bowman Sue (2013) Impact of Electronic Health Record Systems on Information Integrity: Quality and Safety Implications. Perspect Health Inf Manag 1: 10:1c.

8. Weiskopf Nicole Gray, Weng Chunhua (2013) Methods and Dimensions of Electronic Health Record Data Quality Assessment: Enabling Reuse for Clinical Research. Journal of the American Medical Informatics Association 20:144-151.  

9. Hobson Katherine (2010) Web-Based Electronic Health Record Safety Registry Launches. Wall Street Journal Health Blog.

10. Gelzer Reed, Copy Functionality Toolkit: A Practical Guide: Information Management and Governance of Copy Functions in Electronic Health Record Systems.

11. Asan O, Young H, Chewning B, Montague E (2015) How physician electronic health record screen sharing affects patient and doctor non-verbal communication in primary care. Patient Educ Couns 98:310-316.

12. Karsh BT, Weinger MB, Abbott PA, Wears RL (2010) Health Information Technology: Fallacies and Sober Realities. J Am Med Inform Assoc17: 617-623.  

13. Singer Stacey (2010) Electronic Medical Records May Cause Patient Care Errors, Florida Medical Board Says. Palm Beach Post News.

14. Singh Hardeep, Classen David C, Sittig Dean F (2011) Creating an Oversight Infrastructure for Electronic Health Record-Related Patient Safety Hazards. Journal of Patient Safety 7:169-174.

15. Michael G (2015) Why We Must Keep Track of Errors in Electronic Medical Records. Scientific American, 309:5.