The Electronic Health Record: Is It Meaningful Yet?

America is currently in the throes of a national debate on the merits of the electronic health record (EHR). The push for the adoption of the EHR was spurred by the global economic crisis and the increased scrutiny of the safety, quality, and cost of American medical care that ensued.1 The federal government is offering incentives to hospitals and physicians who can document “meaningful use” of the EHR.2 However, for all the attention automation of patient data has received from the press and politicians, its demonstrable value to the practice of medicine remains a subject of debate in the scholarly literature.3,4 Two reports in the current issue of Mayo Clinic Proceedings demonstrate that we are at the threshold of a medical informatics transformation in the United States. Mintz et al5 demonstrate that the Internet enables the identification of patients at risk of airways disease, and Alsara et al6 show that the automated screening of an EHR-derived clinical data repository can identify patients at risk of postoperative acute lung injury far more effectively and efficiently than a manual record search. However, to truly understand the importance of this transformation of American medicine (including medical research), we need to understand more clearly and advocate for the correct acquisition, configuration, implementation, and access to these new information “instruments.” For physicians older than 50 years, the advantages of computed tomography or magnetic resonance imaging over older radiologic technologies were readily apparent, and they immediately embraced, adopted, and incorporated these advances into their practices. Unfortunately, the EHR was all too often introduced to the medical profession as a “replacement” for the paper record, thereby emphasizing the clerical and financial aspects of the tool rather than its clinical importance. What Mintz et al5 and Alsara et al6 teach us is the simple paradigm: “It's all about the data.” The collection of information in a machine-readable manner allows us to extend our communication with our patients, increase our ability to learn from our own practices (regardless of size or specialty), and apply the best evidence—based on our own research literature—to the actual patient care setting. That has been the promise. However, the efficacy of forming connections among the various critical elements of this equation has yet to be consistently demonstrated, validated, and applied clinically. See also pages 375 and 382 One key reason for this disconnect is inadequate physician engagement with EHRs. Although the federal government's Meaningful Use program was designed to provide a more effective “on ramp” for American medicine, it will be unsuccessful nationally if we, as professionals centrally concerned with the quality and safety of the care we deliver to our patients (as well as the responsibility to continually refine medicine through research), remain bystanders or, even worse, refuse to engage in the process. The value of clinical decision support systems has been a subject of considerable debate in the literature this past year, with articles arguing both for and against the demonstrable effect of these systems on patient outcomes. What has not been adequately emphasized is the fact that all medical knowledge requires validation, testing, and retesting. Therefore, if we do not, for example, insist on the reporting of clinical data at the time of the introduction of an EHR, how can we learn and refine our practices with these new tools? Furthermore, if the full communication elements of the Meaningful Use program (eg, health information exchanges, personal health records) are not understood and advanced by us, how will we ever reap the benefits of risk assessment that Mintz et al5 and Alsara et al6 have demonstrated? Bombarded by mounting and sometimes bewildering requests for compliance with new initiatives and for reports of data only loosely tied to the clinical end points they most value, physicians can easily dismiss the Meaningful Use program and this time of transformation as “a great time to retire.” But now is the time for us to engage in this new era of informatics in the practice of medicine. The new opportunities provided by technological management of information are subtle and will not be as easily recognized by physicians as was the case with the clear superiority of the computed tomogram over the radiographic tomogram. However, the importance of this new information management to our profession and our patients is no less profound.