Electronic health records and computer-based clinical decision support: are we there yet?

Electronic health record systems are in different phases of implementation in the US and abroad. From the perspective of enhancing the quality of healthcare, one of the most attractive features of electronic health record systems is the ability to implement computer-based clinical decision support. However, utilization of two main subsets of electronic health record systems, electronic medical records systems (EMRs) and personal health records systems (PHRs), is still very heterogeneous across institutions and individuals. EMRs are not always perceived as advantageous from the standpoint of individual clinicians, with paper records still being the main form of documentation in several institutions. PHRs are still not well integrated into EMRs and their adoption by patients is not widespread. In this issue, we include articles that focus on how electronic health records are being used and how clinical decision support is making an impact on clinical care. Do describes the results of a pilot study on PHR usage and users' perceptions (see page 118). The results are very encouraging, showing that concerns about privacy are not an impediment for use, and that patients perceive benefits in using PHRs that are not tethered to a particular healthcare system. However, more research and further studies in this area are needed. From the clinician's perspective, Hripcsak reports on whether and how notes from an EMR are utilized by members of the clinical team (see page 112). Clinicians spent an average of 54 min/day authoring and 21 min/day viewing notes at one academic medical center. Yet, a significant number of these notes were never viewed. The authors speculate that oral communication at turn of shifts may obviate the role of certain written notes for immediate care. Nevertheless, these notes are still important for documentation, and Hripcsak's study should motivate more research in this area. Developing new ways of documenting oral communications and evaluating the balance between clinical usefulness and legal documentation in electronic health record systems will require multi-centric studies conducted by multidisciplinary teams of researchers, since ease of use and decreased time in documentation are very important factors in EMR adoption. Related to this topic, Rosenbloom discusses tradeoffs between structured and narrative text entry in EMRs (see page 181). Aziz briefly presents personal sensors that can augment health data collection in the home environment (see page 156). Also related to usability of EMRs are the articles by Sykes on clinician attitudes related to EMR implementation in an Emergency Department (see page 125), by Pearce on whether computers intrude on the relationship between physicians and patients (see page 138), and by Vest on factors that motivate health information exchange (see page 143). Use of an electronic health record system is the first step toward computer-based clinical decision support systems (CDSs). Different outcomes for CDSs are reported in this issue. Positive results in real clinical settings are reported by Were (see page 150 on improved CD4 monitoring for people living with HIV), Haynes (see page 164 on improved discontinuation of antibiotics after surgery), and Zlabek (see page 169 on improved patient safety markers after implementation of a commercial EMR). Florez-Arango also reports increased adherence to guidelines by healthcare workers using CDSs on mobile devices in a controlled experimental setting (see page 131). El-Kareh, on the other hand, describes and discusses a case in which such improvements could not be realized (see page 160). Furthermore, CDSs are not easy to design, implement, and maintain. Wright discusses the difficulties in maintaining knowledge bases for CDSs and how the governance structure in different institutions is organized to address this issue (see page 187). Moreover, Liu evaluated methods for evaluating clinical information systems (see page 173 and accompanying editorial by Lehmann on page 110). Lastly, trained professionals are needed to design, implement, and evaluate electronic health records systems and CDSs. Kampov-Polevoi surveyed training programs and confirmed that electronic health records and computer-based CDSs are core components of biomedical and health informatics curricula in the US (see page 195). We hope that this issue of JAMIA will communicate to clinicians, researchers, healthcare administrators, and many other decision makers the relevant, new, and actionable information related to usage and usefulness of electronic health record systems and CDSs.