Health Affairs: EMR adoption could prove difficult

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Providers and policy makers should consider alternative software and informatics models before investing in currently available EMR systems, according to Rushika Fernandopulle, principal with Renaissance Health in Cambridge, Mass., and Neil Patel, associate medical director of the AtlantiCare Special Care Center in Atlantic City, N.J., in an opinion article in the April edition of Health Affairs.

In 2006, nonprofit health system AtlantiCare and the Hotel Employees and Restaurant Employees International Union, Local 54 Fund, partnered with healthcare company Renaissance Health to build a primary care practice called the Special Care Center. The practice opened in July 2007 to a limited group of patients by invitation only, and by the beginning of 2010, the practice had enrolled 1,200 patients.

“Because we were building the practice from scratch and planned to use objective clinical data to optimize patient management, we decided to use an EHR [from eClinicalWorks] rather than paper charts,” stated the authors.

Ferandopulle and Patel said they initially experienced several benefits from using an EMR, including accessible charts that reduced the need to hunt down records, readily available information, reduced time inputting notes, electronically stored medication lists and easier facilitation of communication with consultants.

However, the authors noted some challenges the EHR implementation also presented that would “complicate any medical practice.”

Accurate medication lists

According to the authors, the biggest challenge they faced was maintaining accurate medication lists for their patients. “By design, our patients are all on multiple medications. A root cause of our medication-list inaccuracies has been the interdisciplinary nature of our care model. Most EMRs … are designed and tested for use by a single user in a single office setting. The complexities of multiple practices across a health system, coupled with the complexities of multiple users in an interdisciplinary practice, have had unintended consequences.”

Sluggish and unreliable software

“About a year into the practice, the system began to slow. At times, several seconds to a minute elapsed between each click or action, dramatically slowing down work flow and often requiring a rebooting of the system,” wrote the authors.


According to the authors, e-prescribing presented another challenge. A security glitch was discovered that allowed any user to send an electronic prescription in the name of any other provider; a glitch that took about six months to fix. During that time, paper prescriptions were printed, signed and ran up and down stairs. “When the EMR vendor finally provided an update that solved the security issue, we started to send all of our prescriptions to our pharmacy electronically, which saved time and reduced chance of errors,” noted the authors.

Communicating lab results

The corporate IT department is working with Wellogic in Cambridge, Mass., to create an interface between AtlantiCare’s clinical lab system and eClinicalWorks. The EHR has the capability to use flow sheets to track values over time but AtlantiCare has not been able to use this feature because the lab data has yet to arrive in electronic form, according to Ferandopulle and Patel.

Clinical alerts and warnings

AtlantiCare turned off this feature soon after starting the EMR system because, according to the authors, it was alerting potential problems involving “almost every single patient” in a manner that “caused to be useful, and full-fledged ‘alert fatigue’ was in danger of setting in.”

“Any practice trying to implement an EHR could face problems with system instability, e-prescribing, lab interfaces, data entry, alerts and medication lists. These problems are all theoretically solvable, but the face that our tech-savvy staff had difficulties…should sound a cautionary note,” the authors wrote.

“It is perilous to draw broad conclusions from the experience of a single practice, particularly one such as Special Care Center, which is unique in design and experiment,” Ferandopulle and Patel wrote. “That said, we believe our experiences provide important lessons for the many practices about to implement EHRs, especially those engaged in practice redesign, as well as those that support such endeavors.”