Implementing an Electronic Medical Record System: Successes, Failures, Lessons

In this manual from a Kaiser Foundation Hospital, physicians and health researchers share the actual implementation challenges faced by a large health care system. They report the experiences of clinicians and department managers as well as their back-and-forth interaction with the implementation team. Early on, the authors decided that their best contribution would be to challenge accepted wisdom about electronic medical records (EMRs). They specifically seek to contrast the realities they experienced against the sales pitches they had heard from vendors and consultants.

This is not a cookbook or a how-to guide. Instead, the authors let physician survey findings and clinicians' constructive criticism speak for themselves. They then add commentary with scholarly detachment. They challenge conventional wisdom with fact-based recommendations based on analysis of convincing data and insightful anecdotes from practitioners. Most of all, the authors want readers to recognize “paper thinking” in office practice and to rewire the architecture of their protoplasmic thinking, recording, and actions.

The authors are careful to offer lengthy quotations from front-line physicians and clinicians in the trenches of office practice. This “documentary” approach is seldom tedious and allows readers to sink into the experience and to understand issues more profoundly, beyond the hardware and software challenges. Processes of care that are functional before implementation can become dysfunctional after implementation. Organizational values and culture are very different from one health care system to another, and those cultural values may inhibit truthful communication and feedback to an implementation team. Physicians may be too proud to admit that software is challenging, or they may not want to be viewed as whiners or complainers. Additionally, the authors observe that different medical specialties have different thought processes, office flow patterns, and documentation realities. Accordingly, the dimensionality of EMR implementation and applications must address these challenges. The authors also point out that, when it comes to EMRs, one size cannot fit all.

One drawback is that the authors felt compelled to share a lengthy (23-page) history of the founding and growth of Kaiser Permanente, documenting the growing pains it experienced along the way. If you are a historian of staff-model health maintenance organizations you might find that account riveting, but I respectfully recommend that most readers skip the remainder of the introduction after page 6.

The authors' findings are similar to those of Baron,^{1 - 2} who studied EMR implementation and its application to clinical quality improvement at a nonacademic urban-suburban practice in Philadelphia. The cultures and demographic environments of Northern California and Hawaii, where these Kaiser researchers performed their underlying research, are more diverse than is typical of the heartland United States or many urban-suburban settings in this country. Failed implementation can be a relative success, because failures can be debriefed. In performing serial debriefings, clinicians and the organization can become more prepared for follow-up thinking and actions for small sequential successes.

The final chapter organizes and summarizes the lessons learned. It touches on generic choices of EMR options, software design constraints, impact on clinician productivity, changing roles, and managing physician frustrations. This chapter is a pithy, 5-page summary of the whole book. While this summary is decent, the book would make a better contribution overall if the authors had expanded this section over 2 or 3 chapters with more discussion and more integration of their literature references. I particularly found appendix A interesting, because it serves as a launching pad to help readers craft their own medical group surveys for performing baseline observations and measuring survey data over subsequent improvement cycles.

The authors make a convincing analogy that changing to EMRs will require different rules of the road if the speed limits on the information superhighway are to be smoothly reached. To paraphrase and add to the analogy, the old 20th-century exits, entrances, and stoplights do not work seamlessly when the logic of clinical decision and treatment flow becomes—as is currently the case—both inbound and outbound, truly 3-dimensional. Many processes now must be rethought, and some must be redesigned, to accommodate the new capabilities.