The Problems With EMR

What's holding practices back from adopting electronic medical systems? Why are predicted efficiencies not materializing?

The Problems With EMR

What's holding practices back from adopting electronic medical systems? Why are predicted efficiencies not materializing?


According to the National Center for Health Statistics' preliminary report for 2008, 38.4% of physicians reported that they are, at least in part if not fully, using electronic medical record (EMR) systems.1 This is up from the last complete study, conducted for 2006, when nearly 10% of practices had adopted EMR. However, there remains more than half of the office-based medical community that has opted out of EMR. The reasons these physicians give include financial barriers to adoption, perceived shortcomings of EMR systems, incompatibility with their practices' equipment, medicolegal concerns, and reluctance due to the learning curve.


The most common reason that physicians give for not implementing EMR in their practices is the cost.2 The combined expense per physician when implementing EMR runs between $15,000 and $125,000.3 Depending on the size of a practice, this can be an enormous outlay. This is why adoption of EMR is nearly half in large practices but only around 10% in practices of three doctors or fewer.4

In August 2009, the Obama administration announced that grants of nearly $2 billion would be made available to help hospitals and healthcare providers implement EMR systems.5 These grants, part of the American Recovery and Reinvestment Act, will be available next year. Similarly, in April 2009, Sen. John D. Rockefeller IV of West Virginia introduced legislation to provide open-source software to “safety net“ healthcare providers and to rural practices, although that legislation has stalled in committee. Whether this bit of stimulus money from the government will encourage physicians to adopt EMR is questionable, particularly when privacy concerns are brought into the picture.

Usha Chakravarthy MD, professor of ophthalmology and visual sciences at Queens University in Belfast, says of EMR, “The strengths are very obvious. On the negative side, apart from initial outlay, there are financial implications for the maintenance and support for EMR. Tools for interrogation of the database and outputs that are generated can be rather basic. Also, data exports are not very easily incorporated in statistical packages for analysis.“

Thus industry must provide solutions to the cost problem to help ease the financial burden that especially small practices may feel due to transitioning to EMR. Producers of EMR software, for example, rely on promoting the financial benefits once EMR is implemented as selling points. For example, one producer of EMR software lists the financial benefits of installing its product as increased productivity, greater revenue, cost avoidance and larger profit.6 While no specific monetary gains are cited, losses due to coding errors and money spent on transcription costs are cited as being as high as $50,000 per physician per year. This is money that would not be lost if an EMR system were in place.

An ophthalmology-oriented EMR program.


One physician who implemented EMR in her practice listed three chief shortcomings that she saw with EMR: non-integration of medical laboratory and other clinical data; failure to include patients' original documents and correspondence; and system crashes.7 Taking the last issue first, there is an inherent danger in switching over to EMR in that you will be relying wholly on a computer system for your record-keeping, and it is possible that this system could significantly fail. While advances in hardware and software technology should make these crashes rare, they cannot be eliminated entirely. The best protection against system crashes is regular and thorough backing up of data.

The two initial concerns raised by the physician are largely matters of how well integrated the software and hardware components of an EMR system are. There is no reason why original documents and correspondence cannot be scanned into an EMR system and stored there; all that's needed is a scanner and the right imaging software. The challenge for EMR vendors is to be able to provide hardware and software that can do these things in unison.

The same thing goes for the integration of laboratory and other clinical data into EMR systems, although the situation here is somewhat more complicated insofar as the ability to keep these data in an EMR system may depend on whether the lab or other facility providing the data is transmitting it in a digital format compatible with your own EMR.


The issues of integration of documents and lab data point to the larger issue of system incompatibility. One initiative launched to deal with this issue is the Continuity of Care Record (CCR) standard specification developed by ASTM International, formerly known as the American Society for Testing and Materials. CCR encodes data in XML (extensible markup language), thus, in theory, making it readable by any number of EMR systems.

However, the US Healthcare Information Technology Standards Panel has opted instead for the Continuity of Care Document (CCD) standard, rather than CCR. CCD was developed by combining elements of CCR with the Clinical Document Architecture (CDA) promulgated by Health Level Seven (HL7), the not-for-profit group that tries to develop medical industry standards. Because CCD, CCR and CDA all use XML, it would appear that there will not be a permanent “church-and-state” separation between one standard and the other. Rather, it is likely that one platform will be adopted over the other and push the other out, much in the same way that, before the DVD era, VHS formatting of video cassettes pushed out Betamax.

The problem is that, in the meantime, it is largely still a matter of guesswork as to whether CCR or CCD will become the standard across the board. This understandably has led to reluctance to convert to EMR systems by many physicians. However, the CCR and CCD formats have proved to be largely compatible, so this should not remain a major factor in preventing offices from implementing an EMR system. Furthermore, as more doctors in different fields migrate toward one format or the other, the choice will become more clear. At this writing, neither the ASRS nor the AAO has endorsed one format or the other.

There are signs of compatibility, however. Michael G. Trese, MD, of the Eye Research Institute at Oakland University in Rochester, MI, reports, “Our group has not yet moved to a complete EMR, but we have developed a system that allows retinopathy of prematurity consults to be remotely read and electronically incorporated into the hospital EMR seamlessly.”


By far, the largest medicolegal concern expressed by physicians reluctant to adopt EMR systems is privacy. While HIPAA ensures the privacy of information collected about patients, the ease of transferring this information electronically once it is inputted into an EMR concerns some privacy experts. One solution that has been offered is the development of an anonymous, patient-based system.9 The downside here is that most patients, unless they're also doctors, don't have the level of knowledge necessary to complete an EMR to the extent that it would be useful in the case of referrals, insurance carriers, and other people who would need to access the record.

To a certain extent, the concerns over privacy seem to preclude EMR systems and laws such as HIPAA from coexisting. As an increasing number of states pass laws that augment the privacy provisions already in HIPAA, the number of hospitals implementing EMR systems has fallen.10 However, at the same time, it appears that the driving force behind these privacy concerns is not the individual physician or the hospital, but rather the patients themselves. One way, therefore, that practices may ease the transition to EMR is to better educate their patients to convince them that their medical information will remain as private as it always was.

Another significant legal concern that causes doctors to be reluctant to implement EMR systems is the very question of whether the EMR system they intend to install protects them legally. A Supreme Court ruling in 2006 found that electronically stored data may be subject to subpoena.11 Physician liability thus becomes a major concern, and even small issues such as password security take on grave significance. One way of making sure that an EMR system is up to legal snuff is to have it certified by an organization such as the Certification Commission for Healthcare Information Technology. Information on this organization is available online at

At this writing, however, no ophthalmology-specific EMR system is CCHIT-certified.


Despite the aptitude that most physicians must demonstrate to enter their profession, the issue of a steep learning curve when implementing an EMR system remains a principal reason why practices are not going digital. The perceived difficulties usually lie with the staff rather than the physicians, although in a practice where the doctors are a generation or two older, that learning curve may apply to them as well.

This is one reason why any practice considering implementing an EMR system should probably consider instituting a training program for all employees that will be using the system. One suggestion to ease the training process is to survey the staff to determine levels of knowledge about computers, software, and other aspects of EMR and then to design the training based on the knowledge level already present.12

There will, however, always be plateaus in any learning curve, so practices should expect that, while the staff will ultimately become comfortable with the new system that is installed, there will still be a period of adjustment with using the system and oversight must be undertaken to prevent mistakes from being made.


According to Steven Schwartz, MD, of the Jules Stein Eye Institute in Los Angeles, “The transition to an electronic health record continues to follow a predictable trajectory, hitting virtually every cliché barrier along the way: fear of change, costs, risk that return on investment calculations are exaggerated, shortcomings of available products, integration with current practice patterns, integration with hospital-based enterprise software and proprietary imaging software, reliability, and service issues, among others. So far, the only E in our health record is the one in the word 'paper'! That said, our institute's leadership is navigating these issues and continues to move toward an electronic health record. I am actually cautiously optimistic.”

The reluctance of many physicians, practices and even hospitals to implement EMR systems may soon have a legal cost. Several healthcare reform plans under consideration include provisions for EMR that will become mandatory. Furthermore, the Physician's Quality Reporting Initiative, which requires EMR to work, is also expected to become mandatory in the near future.13 Noncompliance at that point could become expensive to a practice, if not existence-threatening. While the barriers to implementing EMR listed above may be significant and very real, it seems clear that EMR is the wave of the future. Resistance may ultimately be futile. RP


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