EDITOR---This communication in response to the paper on Kaiser
Permanente’s experience with the implementation of an electronic medical
record (1).
The study describes the attitude of 26 clinicians, managers and
project team members to the failed implementation of an electronic medical
record. The limitations of electronic medical records to address the
expectations of its users are the main reason for negative feelings. The
design and user-friendliness of any electronic record are important, but
there is much more than that. Any electronic record is inferior, compared
to paper record, in at least the following items:
1. The amount of textual information presented on one screen is about
a fifth of information presented on one hand-written folio paper. For many
clinicians this is a major difficulty when they review a record. Browsing
through five folio pages is much easier than through twenty five screens.
2. Entering data by typing is slower than handwriting and choosing
from menus expose the users to lists of items that are irrelevant to the
current patient. By that, the clinician's flow of ideas and the thread of
mind are jeopardized.
3. By documenting in the electronic record, the clinician has to look
alternately between the keyboard, and the screen. It is necessary to check
for mistakes and correct them. When using a pen, the clinician has to look
only at the tip of the pen. The presence of a patient adds another point
in space for the clinician to look at. The end result is that while using
a computer, eye contact between the patient and the clinician is of short
duration at a time and of less total time for each encounter. This is a
major drawback to the patient-clinician communication that adds to the
dissatisfaction of both.
4. The electronic medical record is generating a plethora of
unrealistic expectations that the paper record users do not dare to dream
about. These include the idea that the electronic medical record will
enable clinicians to better serve more patients at the same amount of
time.
5. The electronic medical record threatens the sense of autonomy and
privacy of the clinician. With the electronic record, administrators,
colleagues and quality assurance personnel can easily access and criticize
one's behavior. This is actually happening.
6. For many good reasons, an electronic medical record is structured
and demands high level of uniformity. These result in limitation of the
diversity that is needed by clinicians as a result of their medical
backgrounds, specialties or personal style.
Electronic medial records are already in use for many years. They are
getting more users friendly and their abilities to accommodate their users
dreams are in progress. Technical innovations, as increased in computers
speed, memory and communication are of great help. The major difficulties
with electronic medical records are in the change that they impose on the
users. Primarily, this is not related to technology, but rather to human
psychology. The basic rules of implementing a technology are well
established. These include a design that addresses user's needs and
expectations. Communication with the users, flexibility of the design and
local tailoring are important.
This is a continuous process, which also means that investments in
maintenance of electronic medical record in never ending. Failure to
recognize the inferiorities of the electronic record as described above
and failure in compensating them by addressing the user's needs and
expectations are the recipe for failure.
AFFILIATION
Jacob Urkin, MD, MPH, is a primary pediatrician and also director of
the Pediatric Primary Care Unit, Faculty of Health Sciences, Ben-Gurion
University of the Negev, Beer-Sheva, Israel. E-mail: jacobur@clalit.org.il
Mohammed Morad, MD, is a family physician, the medical director of a
large area clinic in the city of Beer-Sheva, Israel. E-mail: morad62@barak-online.net
Joav Merrick, MD, DMSc is professor of child health and human
development, director of the National Institute of Child Health and Human
Development and the medical director of the Division for Mental
Retardation, Ministry of Social Affairs, Jerusalem, Israel.
E-mail: jmerrick@internet-zahav.net. Website: www.nichd-israel.com
REFERENCES
1. Scott JT, Rundall TG, Vogt TM, Hsu J. Kaiser Permanente's
experience of implementing an electronic medical record: a qualitative
study. BMJ 2005;331:1313-6.
2. Urkin J, Goldfarb D, Weintraub D. Introduction of computerized
medical records. A survey of primary physicians. Int J Adolesc Med Health.
2003;15(2):153-60.
3. Warshawsky SS, Pliskin JS, Urkin J, Cohen N, Sharon A, Binztok M,
Margolis CZ. Physician use of a computerized medical record system during
the patient encounter: a descriptive study. Comput Methods Programs
Biomed 1994;43(3-4):269-73.
Competing interests:
None declared
Competing interests:
No competing interests
04 December 2005
Jacob Urkin
Director
Mohammed Morad and Joav Merrick
Pediatric Primary Care Unit, Ben Gurion University, Box 653, 84105 Beer-Sheva, Israel
Rapid Response:
A recipe for failure
EDITOR---This communication in response to the paper on Kaiser
Permanente’s experience with the implementation of an electronic medical
record (1).
The study describes the attitude of 26 clinicians, managers and
project team members to the failed implementation of an electronic medical
record. The limitations of electronic medical records to address the
expectations of its users are the main reason for negative feelings. The
design and user-friendliness of any electronic record are important, but
there is much more than that. Any electronic record is inferior, compared
to paper record, in at least the following items:
1. The amount of textual information presented on one screen is about
a fifth of information presented on one hand-written folio paper. For many
clinicians this is a major difficulty when they review a record. Browsing
through five folio pages is much easier than through twenty five screens.
2. Entering data by typing is slower than handwriting and choosing
from menus expose the users to lists of items that are irrelevant to the
current patient. By that, the clinician's flow of ideas and the thread of
mind are jeopardized.
3. By documenting in the electronic record, the clinician has to look
alternately between the keyboard, and the screen. It is necessary to check
for mistakes and correct them. When using a pen, the clinician has to look
only at the tip of the pen. The presence of a patient adds another point
in space for the clinician to look at. The end result is that while using
a computer, eye contact between the patient and the clinician is of short
duration at a time and of less total time for each encounter. This is a
major drawback to the patient-clinician communication that adds to the
dissatisfaction of both.
4. The electronic medical record is generating a plethora of
unrealistic expectations that the paper record users do not dare to dream
about. These include the idea that the electronic medical record will
enable clinicians to better serve more patients at the same amount of
time.
5. The electronic medical record threatens the sense of autonomy and
privacy of the clinician. With the electronic record, administrators,
colleagues and quality assurance personnel can easily access and criticize
one's behavior. This is actually happening.
6. For many good reasons, an electronic medical record is structured
and demands high level of uniformity. These result in limitation of the
diversity that is needed by clinicians as a result of their medical
backgrounds, specialties or personal style.
Electronic medial records are already in use for many years. They are
getting more users friendly and their abilities to accommodate their users
dreams are in progress. Technical innovations, as increased in computers
speed, memory and communication are of great help. The major difficulties
with electronic medical records are in the change that they impose on the
users. Primarily, this is not related to technology, but rather to human
psychology. The basic rules of implementing a technology are well
established. These include a design that addresses user's needs and
expectations. Communication with the users, flexibility of the design and
local tailoring are important.
This is a continuous process, which also means that investments in
maintenance of electronic medical record in never ending. Failure to
recognize the inferiorities of the electronic record as described above
and failure in compensating them by addressing the user's needs and
expectations are the recipe for failure.
AFFILIATION
Jacob Urkin, MD, MPH, is a primary pediatrician and also director of
the Pediatric Primary Care Unit, Faculty of Health Sciences, Ben-Gurion
University of the Negev, Beer-Sheva, Israel. E-mail: jacobur@clalit.org.il
Mohammed Morad, MD, is a family physician, the medical director of a
large area clinic in the city of Beer-Sheva, Israel. E-mail:
morad62@barak-online.net
Joav Merrick, MD, DMSc is professor of child health and human
development, director of the National Institute of Child Health and Human
Development and the medical director of the Division for Mental
Retardation, Ministry of Social Affairs, Jerusalem, Israel.
E-mail: jmerrick@internet-zahav.net. Website: www.nichd-israel.com
REFERENCES
1. Scott JT, Rundall TG, Vogt TM, Hsu J. Kaiser Permanente's
experience of implementing an electronic medical record: a qualitative
study. BMJ 2005;331:1313-6.
2. Urkin J, Goldfarb D, Weintraub D. Introduction of computerized
medical records. A survey of primary physicians. Int J Adolesc Med Health.
2003;15(2):153-60.
3. Warshawsky SS, Pliskin JS, Urkin J, Cohen N, Sharon A, Binztok M,
Margolis CZ. Physician use of a computerized medical record system during
the patient encounter: a descriptive study. Comput Methods Programs
Biomed 1994;43(3-4):269-73.
Competing interests:
None declared
Competing interests: No competing interests