ELECTRONIC HEALTH RECORDS IN ACADEMIC FAMILY MEDICINE PRACTICES: A TALE OF PROGRESS AND OPPORTUNITY

The Future of Family Medicine report called for an electronic health record (EHR) that assures integration of clinical information; provides decision-support based on evidence-based guidelines; generates chronic disease registries; tracks health maintenance interventions; and supports practice-based research and quality improvement activities. Yet, the substantial organizational, financial, and intellectual challenges of implementing EHRs in academic departments have been previously outlined.¹ ADFM recently conducted an all-member electronic survey (response rate 61%) to assess the status of implementation within the context of these challenges. Sixty-two percent of the department clinical practices are owned by their universities and 25% by their sponsoring hospital. The overwhelming majority (89%) include faculty and learners practicing together, highlighting the imperative we have to model effective practice redesign.

Nearly all respondents have either implemented EHRs (72%) or plan to within the next 12 months (18%). Use of EHRs is a relatively new experience for departments, with 64% reporting use for 5 years or less. This level of incorporation is likely enabled by the fact that the majority of these systems are owned and upgraded by the university (38%) or health system (34%), with only 12% of departments owning their own EHRs.

Clinical information is largely recorded (61%) through a mix of template and free-text entry. Nearly all EHRs (87%) have prescription writer capabilities, and 89% provide drug safety information at the point-of-care. However, only 38% provide drug cost information and fewer than one-half (49%) provide drug information handouts for patients. In nearly two-thirds (65%) of cases, lab studies and other ancillaries flow into the chart electronically, allowing for serial comparisons.

Quality improvement capabilities of EHRs are insufficient. Over one-half (53%) report having no built-in point-of-care decision support; though nearly one-third (29%) plan to have such within the year. Only 42% of the time is decision support available for clinical preventive services, while fewer than one-third (31%) of respondents report having chronic disease care reminders. Lack of patient registries is a similar barrier to the provision of high quality disease care, with an astonishing 61% of departments reporting that they do not have a functioning registry within their EHR. A number have addressed this by creating or purchasing their own superimposed registry.

Two-thirds (67%) of respondents regularly measure quality indicators for their practice(s) as a whole, and one-half (52%) do so for individual clinicians in the practice. Fewer than one-half (49%) of academic practices have HIPAA-compliant Web access for patients. For those who do, 31% have a Web site for practice information; 26% allow patients to request appointments; and 23% have capability for patients to request prescription refills. Only 15% allow for e-visits with a nurse or clinician, while only 8% allow patients electronic access to portions of their health record.

Academic practices face 2 imperatives: providing high quality care to their patients, and effectively demonstrating elements of the patient-centered medical home to students, residents, and our parent health systems. This survey of academic departments suggests that EHRs are quickly becoming a reality in our teaching practices. While we have benefited from the start-up capital and technologic expertise offered by our large, affiliated health science centers, we are also struggling with the challenges of slow implementation and lack of incorporation of important items such as decision support, registry use, quality indicator reporting, and electronic communication that are hallmarks of the Future of Family Medicine report.

Our departments must take an active role in the redesign of our teaching practices to be patient-centered medical homes (PC-MH), maximally utilizing available technology to aid in this journey. Our parent health systems may not share this vision, and thus, may not be responsive to our needs and requests. Hiring or training faculty members who are technologically savvy will help develop the internal expertise we need to modify our EHRs for more rapid improvement efforts. We must also be strong advocates for, and demonstrate the effectiveness of, a well-designed ambulatory EHR in helping us provide higher quality care at a lower cost to the patient and the health system. This initially may require creating or purchasing our own “add-ons”, such as disease registries or secure practice Web sites for e-visits. Ultimately, playing a central leadership role in system-wide EHR implementation or revisions will likely to produce substantially better, and more sustainable, results. Much education remains to be done, and there is a compelling need for us to find ways to sell this vision to our health systems, lest we lose the opportunity to truly model patient-centered practice to our learners.

• © 2008 Annals of Family Medicine, Inc.