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02 Dec 2019


By now, most have been exposed to the electronic medical record (EMR), also known by a number of related terms such as electronic health record (EHR) and electronic patient records (EPR). I have presented twice within a fortnight on the topic of EMR, with a focus upon the EMR’s impact upon medical education and training. However, like all things in medicine; this impact is not limited to teaching and training but extends across all industry domains; from morbidity and mortality, hospital productivity, ethics, privacy and confidentiality, patient satisfaction, physician well-being and team dynamics.

Feedback from both presentations illustrated high levels of frustration and fatigue associated with EMR implementation and use; and minimal awareness about EMR’s multidomain impact. The consensus from both presentations was that EMR discourse must remain front and centre during these tenuous years of implementation and complete integration into our healthcare system.

EMR was first propositioned as a legitimate replacement of paper records in the early 1980s and by 2004 the need to convert medical records from paper to screen became a priority. Despite the passage of years, EMR is still in a nascent form; hampered by financial, time-related and technical factors; as demonstrated by two systematic reviews in Canada, one in 2009 and a follow-up in 2014.

I will provide a multidomain ‘impact report’; by no means complete, but I hope readers will conclude, to quote Mark Twain, “there was food for thought there”.


Ineffective, inadequate and time-consuming EMR training is a continued bugbear of clinicians where all are deemed computer novices who need to complete all possible EMR tasks. Seven hours of indiscriminate training has proven ineffective; time and time again, but this mode of training continues to be mainstay. The Fiona Stanley Hospital in Western Australia demonstrated marked improvement in EMR literacy with specific task and ward-based training. Competency at a few key role-specific tasks was assessed via mouse click numbers and time to task completion. Another overseas study demonstrated that simulation-based training, with immediate feedback on key learning objectives, increased EMR adoption by 70 per cent.


It is a chilling statistic, but patient mortality and morbidity increases for up to 12 months during EMR implementation; as published by BMC Medical Informatics and Decision Making. Factors were multifactorial but included poor training and software design. Furthermore, there is a global hospital productivity dip that can last for as long as 18 months during the EMR Go-Live period, irrespective of whether there is a phased EMR implementation, or the so termed ‘big-bang’ implementation.


EMR drug prescribing is frequently the first EMR capability to be adopted, offering a number of benefits over paper charts by circumnavigating illegible handwriting, providing warnings about potential drug interactions and reminders if drugs are overdue. However, alert fatigue can result in these warnings being ignored, or automation bias can result in genuine alerts being dismissed.

Ward Rounds

During ward-rounds, the EMR can impede multidisciplinary exchange, as the once communal paper chart is now under the sole ownership of the one standing at the Computer on Wheels (COW), whose ergonomics creates unequal information access. This sole ownership can disincentivise consultants from probing their juniors for information, as the consultant can quickly access all notes with a few clicks. Some medical students report internship ill-preparedness, as the opportunity to practice notetaking during ward rounds becomes impractical, as medical students infrequently have EMR logins. Furthermore, it can be challenging for consultants to determine a trainee’s competency, as a trainee who is EMR proficient may ipso facto appear clinically competent with no correlation to their knowledge or clinical reasoning.   


But it is not all EMR doom and gloom. A number of DiTs report increased consultant feedback on their EMR discharge summaries compared with paper equivalents. And EMR notes are frequently rated of higher quality and with greater details, especially notes pertaining to pain and mobility assessments. That is, as long as notes are not needlessly inflated with volume and irrelevant content; or with perpetrated errors from copying and pasting previous entries.


Time spent on EMR documentation is dependent upon post-graduate year, time of the year and most interestingly, sex. Males DiTs spend 25.2 hours weekly to females’ 15.6 hours; and interns spend 41.4 per cent of their week compared with PGY +4 who spend 28.8 per cent of their working week on EMR documentation. Compare all of these numbers with the ~22 per cent of time on documentation when paper charts predominated.


EMR can provide excellent ‘just-in-time’ education through ready access to point-of-care knowledge, up-to-date information, guidelines and algorithms; all of which would otherwise be added to a long after work to-do-list of things to look up. Ease of remote EMR access equally has pros and cons. Trainees can look up patients for the following day’s theatre schedule without coming in on a day off, but this can creep into the expectation of a 24-hour knowledge of patients’ investigations and progress.


There is an emerging 30 per cent rule with EMR: >30 per cent of clinical time is spent on EMR, 30 per cent of EMR use occurs outside of paid and rostered work hours and there is a 30 per cent higher burnout rate with EMR use. In November of this year, the Mayo Clinic published a strong dose-response relationship between physician burnout and poor EMR usability; using a standardised metric of technology usability, with EMR usability being awarded an F.


Patient centredness is one of the first negative sequalae of EMR use as the dyadic doctor-patient relationship has become triadic where an interactant, the computer, must be incorporated into the consultation to prevent alteration of the power and authority between patient and doctor.  A number of EMR specific skills have been advocated to reduce the impact of the EMR; everything from learning to touch-type, to signposting the transition between reviewing, writing and interacting. But how these skills will be acquisitioned has yet to be enumerated and may need incorporation into medical school curriculums.


EMR privacy and security has been rated a low concern for clinicians but a high concern for patients, to the point that patients may delay hospital presentations or withhold information. At one Victorian hospital, all medical staff received an email to say the EMR had been inappropriately accessed by staff and was therefore a potential significant breach of privacy, risking formal legal penalties. Has accessing medical record behaviour changed between paper notes and EMR implementation, or has the ease of monitoring medical record access via EMR, inadvertently exposed clinicians to formal penalties without adequate education to smooth the transition?    

I hope this snapshot of an emerging and current dilemma will encourage increased and ongoing discourse, research, out-reach and a pre-emptive approach to the EMR sleeping dragon.   

Published: 02 Dec 2019