In the 1960s, health care visionaries began advocating replacement of paper medical records with a computer-based version. Although progress has been made in some quarters, including the Harvard-affiliated hospitals, nationwide the 30 years since the idea of the electronic medical record (EMR) was introduced have seen relatively little implementation. Last year, the Institute of Medicine lamented this languid pace:

"Until EMR use becomes the norm for all practitioners across all provider settings, we will continue to lack the tools needed to manage the quality and costs of health care, the scientific basis for health care will continue to be undermined, and the dramatic transformation of health care so urgently required will be impeded."

Four of the 10 pioneers in the EMR cited in the Institute of Medicine’s report were Harvard-affiliated institutions. The development of the MUMPS language at the Massachusetts General Hospital (MGH) was an important tool used for building the first version of the EMR implemented by Harvard Community Health Plan. Early implementation of more networked versions of the EMR was achieved at Brigham and Women’s and Beth Israel hospitals.

The electronic medical record systems now being implemented in the major Harvard-affiliated integrated delivery systems are industrial-strength EM Rs representing giant investments in research and development involving commercial vendors. This classic transfer of technology from pioneering academic research to commercial products will likely impact the future quality and cost control in health care delivery throughout the United States.

The computer-based patient record will enable health care providers to achieve significant improvements. The ability to share medical records across geographical space enables primary care clinicians and specialists to improve patient care. For example, electronic patient information will enable: medication decision support, patient alerts triggered by electronic monitoring of a patient’s record, and outcomes reporting.

In this Forum, authors Dorothy Wagg, Kim Nelson, Dr. Joseph Kvedar, and Eric Menu make a strong case for caution in the implementation of electronic patient records. The sharing of patient information within telemedicine applications, for example, raises regulatory, malpractice liability, and risk management issues that have not yet been resolved. At the same time, however, the risk management challenge.

Closed Claim Abstract demonstrates a number of ways computerization could have reduced the non-computer systems breakdowns that contributed to a medication error. And, as more clinicians find e-mail a beneficial tool for communications in their medical practice, Charles Conklin points out that we must acknowledge the risk management issues involved with its use.

The IT revolution has spawned many innovative practices which improve the quality and effectiveness of health care. One of the early pioneers, Dr. Warner Slack, offers a valuable perspective on progress in this field over the last three decades, while Dr. Luke Sato describes a more recent application of multimedia for patient-physician communication.

Outside of health care, a large percentage of computerization is simple, at least for the consumer. We go to a supermarket and our purchases are scanned into a cash register; we go on-line to our broker and buy or sell stock by computer. But the computerization of a patient’s medical information makes much of what other industries encounter appear trivial. And, after 30 years of building momentum, the information technology revolution is now hitting medical practice like a tidal wave of change.

Despite the acceleration of progress in information technology support for clinical practice, the road ahead will not be easy, requiring "persistence, patience, thoughtfulness, and commitment". These new technologies and their application to health care are both challenges and opportunities for physicians. New medical practices and error reduction strategies must be implemented. The Harvard-affiliated medical institutions are in a leadership position with good reason to be optimistic about the future benefits for those institutions, clinicians, and patients. •

Notes & References

1.  Safran C.,  The next generation of knowledge—based clinical systems. Forum, April 1996;17(1):3.

2.  Dick RS, Steen EB, and Detmer DE. The Computer-based Patient Record: an Essential Technology for Health Care. Washington, D.C.: National Academy Press (revised edition, 1997). pg. vii.

3.  Glaser JP. Networking the health care system. Forum, April 1996;17(1):5.

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