The King is Partially Dressed: The Imperfect EMR

H. Dominic Covvey, National Institutes of Health Informatics

I thought it might be interesting to reflect on the place the Electronic Medical Record (EMR), the information center of the provider’s practice, has in the discipline of Health Informatics (HI) and what must be done with the EMR to make it really suited for prime time.

This may be obvious to many, but often one or more aspects of the challenge that the EMR represents appears to be forgotten or ignored. I can even go as far to say that virtually every sub-discipline of HI has something, and often a lot, to say about the EMR and how it needs to evolve. I won’t have the space here to go into each of these deeply, but I hope to make it clear that the EMR isn’t done and it ain’t easy! This should make it clear that a great deal more work needs to be done, even on the most advanced products, to realize our hopes and dreams about the EMR.


The EMR as an Information Management Challenge

Deciding what should be in the EMR, and how information subsets should be prioritized, organized and visualized is non-trivial. Our own work resulted in the User-Uses-Effects model (1) that proposes a structured approach to defining the contents of the EMR and how its information is viewed. This model recognizes that different users (e.g., physician, nurse, physiotherapist) will each have different uses of information in the record and that there is the need to quantify to a degree which information will get a piece of the display ‘real estate’. This allocation needs to be based on the particular information’s importance to the outcome of the process depending on the record. That’s just one example. Others include the need for data standards including a usable clinical vocabulary, the internal organization of the EMR database, the types of queries (time-dependence being important) that are possible and even the metadata (units, authorities, sources, security) stored with data. Then there is the challenge of recovering one of the values of the textual paper record: that the textual paper record not only incorporated data items, but told a story by interconnecting those items into a meaningful framework that did more than just hold the data, as the digital record does (2).

The EMR as an Operations Challenge

Anyone who has attempted the introduction of an EMR system knows that the process is very disruptive to normal clinic operations. Many say that this disruption will last at least a year. For many (one research program indicates half of) practices this is enough of a threat that they don’t proceed to implement the EMR component of the system they purchased, thereby essentially wasting their investment. But beyond the issue of disruption, there is the fact that simply tossing a clinic management system into an operational mess will only make the mess swirl faster! It is well established that one must reengineer work processes based on and integrated with the system’s capabilities. People also need to be trained, roles almost certainly need to be altered, obsoleted or created, and the entire process of change needs to be managed. Unless these complementary factors are also addressed, disruption can just be the first step to disaster. Even the issue of procurement of an EMR system is rife with problems, so much so that we have proposed an innovation of the procurement process that we call “re-engineering-driven procurement’.

The EMR isn’t done and it ain’t easy!

The EMR as a Financial Challenge

Introducing an EMR isn’t cheap, as should be clear from the above. However, in this case help is available from OntarioMD and its ilk in other provinces. Regardless, most still expect the cost to be in excess of $10,000 per provider per year…and that can be a real challenge for primary care providers. The argument is that the practice efficiency will improve and some even claim that there will be net actual savings. The evidence of this, however, is spotty. We seem to be quite ‘irrationally exuberant’ when projecting benefits of any eHealth innovations, but we produce little real evidence of actually achieving them. This is a matter for economists, not amateurs, but the famous quotation by the Nobel Laureate Robert Solow still rings true: ”You can see the computer age everywhere but in the productivity statistics”.

The EMR as a Human Interaction and ‘Intelligent System’ Challenge

Our interfaces with systems are still primitive. We still face a challenge in the entry of unstructured information (text, drawings, doodles) that is characteristic of early encounters with a patient and that only, with time, can be structured and tied to diagnoses. Further, it is still rare to find a system where the interface can adapt to the way each different user uses it. Further, it is still rare to find a system where the interface can adapt to the way each different user uses it. The keyboard and mouse and touch screen still dominate, with little support for speech and nothing very sophisticated compared to what’s in our labs. The ‘one size fits all’ interface is just like ‘one drug fits all’ medicine – we need to move to personalized approaches. Not just for input and usage, either, but also for output: the production of personalized reading materials for the patient, with their content and rhetoric suited to the patient’s motivational needs (3).

The EMR as a Social and Organizational Challenge

Using the EMR system during a care encounter can be viewed by the patient as reducing the intimacy of the encounter, and some patients may perceive that the physician is unduly dependent on a system. There are, of course, solutions to this: providing the patient with the view of the same information with back-to-back screens. Research has made it clear that when 2 people get together with a system, the system is an agent in that social encounter, sort of like a third person. That needs to be understood and addressed, or the encounter can be negatively affected. And then there is the impact of systems on the perceptions of other providers in the care team. Larry Weed (the Problem Oriented Medical Record guy) was run out of the University of Vermont hospital when other physicians became incensed that nurses were becoming empowered by Weed’s PROMIS information system. Systems change our perception of each other, affect our self-esteem (positively or negatively), and alter roles.

The EMR as an Infrastructure, Communications and Interoperability Challenge

There will only be limited value of the EMR if it is just used to support the encounter in the office. Rather, this information must become available to others, perhaps via the EHR. This has a number of implications: that the EMR system is technically able to communicate with other systems, e.g., those that enable an EHR to be populated with encounter data or reference to encounter data, that EMR systems adhere to a common data standard, and that the EMR data is organized in a way that allows it to be incorporated into the data structure of the EHR. This means that we need to be able to communicate the EMR and the meaning therein.

The EMR as a Policy and Health System Challenge

Real advance on achieving the benefits of the EMR is frustrated by many policy issues, perhaps the most important being how care providers are reimbursed. As long as it is required that patients be dragged into the office for the care to be reimbursed, providers will not be able to care for patients via portals or other virtual care mechanisms. Last year I attended a very frustrating workshop organized by the Conference Board of Canada. This workshop had the objective of identifying how much information and communications systems could improve the productivity of providers. Unfortunately, the measure of productivity increase was how many more patients could be seen in the office in a given time. This is an unbelievably misinformed and limited concept of productivity, but is clearly built around the assumption that office volume will be the basis for reimbursement. The only answer here is to break out of that model through various capitation schemes, but we are still beset by inheritance. There are many other policy issues, including those surrounding privacy, roles of different providers, and even the organization of our health system that is largely built around the hospital and acute care, rather than around primary care and wellness maintenance.

The EMR as an Evaluation Challenge

Finally, I will point out a major failing of the Health Informatics profession: the failure to evaluate the work we do and to develop hard evidence of the value that our innovations deliver. We all believe in the e-stuff, but we can point to very little evidence that this belief is based on reality. It is not just the economic or efficiency effects that we need to measure, but also the qualitative effects, such as those regarding patient and provider satisfaction, more manageable roles, greater patient involvement and engagement, fewer errors, and many others. It is sad that we have no real evidence of improved patient outcomes and only minimal evidence of efficiency improvement, but it is unforgivable that we have so little hard evidence of virtually any impacts of systems. In other words, we seem to be guilty of the unwillingness to actually assess our work. Given the billions being force fed into eHealth, That is really something that must be corrected.

Last Words

This material does not tell the full story about the challenge of the EMR, in fact it’s just an ‘abstract’. The EMR is a far greater challenge than many of us seem to be willing to recognize. But, if we don’t recognize the challenge, we will oversell the EMR and its benefits, raise expectations to new heights, and under-prepare everyone for the hard work involved in implementing the systems currently available and in creating the systems that must follow.


  1. Covvey, H.D., Berry, D., Zitner, D., Cowan, D., Shepherd, M., Formal Structure for Specifying the Content and Quality of the Electronic Health Record”, Requirements Engineering 2003, September 2003.
  2. Patel, V.L., Kushniruk, A.W., Yang, S., & Yale, J.F., Impact of a Computerized Patient Record System on Medical Data Collection, Organization and Reasoning, Journal of the American Medical Informatics Association; 7(6): 569-585, 2000.
  3. DiMarco, C, Bray, P., Covvey, H.D., Cowan, D.D., Diciccio, V., Hovy, E, Lipa, J., Yang, C., “Authoring and Generation of Individualized Patient Education Materials”, Journal on Information Technology in Healthcare, February 2008.

Dominic Covvey (FACMI, FHIMSS, FCIPS, SMIEEE, ITCP) is an Adjunct Professor at the University of Waterloo and the University of Ontario Institute of Technology. He is also the President and Director of the National Institutes of Health Informatics. He was the Founding Director of the Waterloo Institute for Health Informatics Research at the University of Waterloo (2003-2010). His research is in the representation and analysis of healthcare workflow, the definition of competencies and curricula in Health Informatics and the design of the Electronic Health Record.

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