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When Will Electronic Records Be Required?

Butcher, Lola

doi: 10.1097/01.COT.0000297228.99516.50

Like a tide coming in to the shore, the fact that electronic medical record technology will be required to practice medicine looks ever more inevitable. The early adopters—probably fewer than 15% of practicing oncologists—have already jumped the wave, while their colleagues eye the horizon and wonder how long they can wait.

The answer will vary as each oncology practice weighs the benefits against the challenges of making the transition—even as pressure builds from payers, professional societies, and patient-advocacy groups.

“Electronic records are going to be mandatory for everyone, whether it's by individual physicians realizing that they are the way to go, or whether it's a mandate by payers or malpractice carriers. That I don't know, but at some point it will be mandated,” says Stephen Fox, MD, an oncologist in Paoli, Pennsylvania.

Those at the front of the electronic medical records (EMR) movement expect no official mandate from public or private insurers. But, as physicians are required to report increasing amounts of data to payers and others, using EMR technology will become a de facto requirement for getting paid—possibly as soon as 2012.

“I think it is on the intermediate-time horizon—probably within the next five years,” confirms Mark A. Sitarik, MD, a partner in Rocky Mountain Cancer Centers (RMCC) and one of oncology's most outspoken advocates of EMR technology.

Richard A. Royer, CEO of Primaris, one of many consulting organizations hired by the federal government to speed EMR adoption, urges physicians to get on board before they start losing payers: “Private payers may mandate recordkeeping such that it is going to be impossible if you do not. I am betting that it is going to be such a hostile environment to practice in that you end up spending more money resisting.”

Dr. Sitarik agrees, which is why he devotes much of his time to advocating for the EMR way of practicing medicine. With more than 65 physicians in 20 locations, RMCC began moving to EMR technology in 2004. Today, in addition to his oncology practice, Dr. Sitarik serves as medical director of U.S. Oncology's electronic medical record division.

He said he considers EMR adoption not simply as installing a bunch of computers, but as a transformation of the way oncology is practiced: “This is a sea change, because it changes workflow so dramatically. It changes the focus of recordkeeping from the convenience for the physician to a patient-centered record.”

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What to Watch for

In 2004, President Bush issued a decree that most Americans should have a personal health record in a decade—by 2014. In doing so, he tried to speed the proliferation of EMR technology in hospitals and physician offices, where it has been slow to catch on.

Estimates of EMR use vary widely, but no studies suggest that anywhere near a majority of physicians are on board. The closest thing to an official estimate comes from a study by Catharine W. Burt, EdD, and her colleagues at the Centers for Disease Control and Prevention, which reported that, as of 2005, about 26% of office-based physicians were using an EMR.

Of those, a little less than half used a full EMR, while the majority used a partial EMR. EMR use is more prevalent in primary practice offices than in specialty practices (

EMR proponents say that 2014 should not loom large in the minds of oncologists hesitant to transition to electronic records. Rather, they say, other factors are likely to force physicians in all specialties into the boat before then.

“The long and short of it is, I believe that all physicians, and I would certainly include oncologists in this group, need to be moving into the electronic era, if you will,” Mr. Royer said. “Certainly the need is starting now and for the next five years because several things are going to happen.”

Among them, he said:

  • Payer demands for data. America's most important health care payer—the Centers for Medicare & Medicaid Services—has several pay-for-performance demonstration projects under way, and, in general, CMS officials like what they see.

Mark Wynn, CMS's Director of Payment Policy Demonstrations, says that the first three years of the Premier-CMS Hospital Quality Improvement Demonstration proved to him that P4P initiatives drive quality improvement. Although hospitals are the official participants—and the financial beneficiaries—of that ongoing demonstration, the program hinges on the care provided and documented by physicians.

“We're delighted with the project so far,” Mr. Wynn said, adding that other demonstration projects are coming. “We think it has certainly gone in the right direction in terms of improving quality.”

Meanwhile, private health plans are introducing their own P4P programs, all of which—just like the CMS project—require providers to submit a lot of data. EMR systems do not automatically make data collection and reporting easier, but they have the potential to do so—and that can make them worth the expense and effort.

“If you can provide the data and prove its validity, you are likely to get better pricing in the marketplace,” Dr. Sitarik said. “The way I look at it is you really cannot afford not to do it.”

  • Need for decision support and protocol compliance. As the focus on improving the quality of health care and patient safety continues, oncologists will be increasingly pressured to practice evidence-based medicine, which requires staying apprised of and adhering to new protocols. Not only payers, but professional organizations and patient advocates are calling for reduced variability in cancer care.

“It is much easier to get these types of things through an electronic format and have a computer keep track of how we are managing all these different protocols, than to try to do it manually,” Mr. Royer said.

  • Responsibility for chronic care management. Cancer patients who live years with their disease have long-term relationships with their oncologists and need longitudinal records of their treatments and symptoms.

“Electronic records are much better at keeping track of all those things you are doing than trying to keep it in your head or do it on little pieces of paper that are floating around in cardboard charts,” Mr. Royer said.

  • Competitive pressure. Payers favor oncology practices with EMR technology. In general, larger physician groups are adopting EMR technology more rapidly than smaller groups, according to the CDC study, and that may be more true in oncology than anywhere else.

US Oncology, which provides at least 15% of the nation's cancer care, plans to have all practice locations wired by 2009. That is not to say that oncologists at large groups like the EMR better, but rather they have the financial and technical resources to support the transition.

Within US Oncology, Dr. Sitarik said he has seen his colleagues shift from “tell me why I have to do this” to “tell me when I'm going to do this.”

“The perception that an electronic record is optional has really gone away,” he said. “It is really a matter of when each individual practice has to bite the bullet and change their work flow to get organized around the EMR.”

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Electronic Medical Record vs Personal Health Record

Despite the widespread use of the terms “electronic medical record,” “electronic health record,” and “personal health record,” they are often used interchangeably, which is to say, inaccurately.

The health care industry's primary organization promoting use of information technology—Healthcare Information Management and Systems Society, or HIMSS—published two definitions in 2006:

  • Electronic medical record: A record—maintained, used and owned by a health care provider—that documents, monitors, and manages the health care delivery of an individual patient.
  • Electronic health record: A record—owned by the patient—that includes a subset of information from the electronic medical records of the patient's various health care providers.
  • Personal health record? President Bush in 2004 called for most Americans to have a personal health record within a decade, but the government appears reluctant to define exactly what he meant. According to the Centers for Medicare and Medicaid Services Website: “While a uniform, standard definition does not yet exist, consistent applications for PHRs are beginning to emerge. The ideal is for a PHR to provide a complete summary of an individual's health and medical history with information gathered from many sources, including self-entries.”

The connection between personal health record and electronic medical record is this: If patients are to maintain personal health records populated with information from their health care providers, physicians will have to have electronic medical records that allow the information to be shared.

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Stephen Fox, MD, a solo practitioner in Paoli, Pennsylvania, said that although he intends to eventually buy an EMR system, he is certainly in no rush to do so. He practices in a suburb of Philadelphia, one of America's health care hot spots, where EMR technology is in short supply.

“Even looking at that sophisticated network of physicians and hospitals, there is not systemic medical recordkeeping in this area,” he says. “I certainly do not feel pressured to get it before the big guys do, although I would if I thought the risks were outweighed by the benefits.”

At the moment, he sees the equation tipping in the other direction. As a solo practitioner, Dr. Fox does not think an electronic system would eliminate as much overhead expense as it would for a larger group that practices in multiple sites. Moreover, he practices alone because he believes a single site allows him to monitor every patient's treatment—a safety protocol that he does not want interrupted by technology.

“If I can be convinced that an EMR system would reduce the potential risk of medical errors, I would buy it in a heartbeat, but I am not yet convinced of that,” he says.

So for the foreseeable future, Dr. Fox intends to sit on the EMR sidelines—where he has lots of company.

© 2007 Lippincott Williams & Wilkins, Inc.
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