Baron RJ et al. 2005 "Electronic health records: just around the corner? Or over the cliff?"

Baron RJ, Fabens EL, Schiffman M, et al. Electronic health records: just around the corner? Or over the cliff? Ann Intern Med 2005;143(3):222-226.
"We recently implemented a full-featured electronic health record in our independent, 4-internist, community-based practice of general internal medicine. We encountered various challenges, some unexpected, in moving from paper to computer. This article describes the effects that use of electronic health records has had on our finances, work flow, and office environment. Its financial impact is not clearly positive; work flows were substantially disrupted; and the quality of the office environment initially deteriorated greatly for staff, physicians, and patients. That said, none of us would go back to paper health records, and all of us find that the technology helps us to better meet patient expectations, expedites many tedious work processes (such as prescription writing and creation of chart notes), and creates new ways in which we can improve the health of our patients. Five broad issues must be addressed to promote successful implementation of electronic health records in a small office: financing; interoperability, standardization, and connectivity of clinical information systems; help with redesign of work flow; technical support and training; and help with change management. We hope that sharing our experience can better prepare others who plan to implement electronic health records and inform policymakers on the strategies needed for success in the small practice environment."

To describe the effects that the use of electronic health records has had on a practice's finances, workflow, and office environment.

Tools Used
Type Clinic
Primary care
Type Specific
Internal medicine
Small and/or medium
Other Information
The clinic has one RN, a front desk staff, and several medical assistants. It has no mid-level providers.
Type of Health IT
Electronic health records (EHR)
Type of Health IT Functions
Health IT functions include order entry, e-prescribing, electronic receipt of lab results, and electronic internal messaging.
Context or other IT in place
A practice management system, including scheduling and billing, was already in place.
Workflow-Related Findings
"Although the vendor urged us to think through and document the new work flows in advance, we found ourselves making innumerable decisions about how we would use the system before we really understood how it worked, and our vendor did not know enough about how our office worked to help us. We were forced rapidly to adjust our work flows during implementation, which seemed akin to redesigning an airplane in flight."
After going live, "the front desk had to use new on-screen forms to record telephone messages; pairing electronic messages with paper charts required the file clerks to follow a new work flow; physicians had to find telephone messages on their computer desktop rather than neatly piled in a physical telephone message bin. The medical assistants had to record vital signs and chief symptoms in the computer and had to learn how to record results of a tuberculosis skin test, visual acuity test, or urinalysis."
During the transition to electronic health records, "waiting time for patients dramatically increased."
"Variations in clinical style and work flow among the physicians, which had seemed acceptable if unnoticed before, now became a subject of group scrutiny. What did we have to change, and what could we hang on to? What did the physicians have to do the same way, and where could we tolerate difference? All these issues had to be renegotiated at a time of enormous stress on the practice."
"Every patient represented a "new patient" to the electronic health record, and the old paper chart had to be abstracted and data moved into the electronic chart [by the physician]. Some aspects of chart abstraction could perhaps have been delegated (for example, entering medication lists or immunization histories), but we worried that our staff, who have only limited clinical training, might make mistakes, and decisions about what data to abstract require the clinical judgment of a physician."
"We plan to use our electronic health record to provide [diabetes] patients with an individualized report on services for which they appear to be overdue."
"Despite the difficulties and expense of implementing the electronic health record, none of us would go back to paper. We find ourselves able to be better physicians: We communicate more quickly and clearly with patients on the telephone and by letter, transmit important clinical information (albeit on paper produced automatically by our system) more efficiently to specialists, and spend less time paging through charts to find out what the previous cholesterol values (for example) had been."
"It is possible (although unlikely) that physicians will be less productive because the electronic record generates more work for them. For example, whereas the physicians used to dictate notes, they must now type them. Physicians must also participate more in "filing." Our electronic system offers us 24 "document types" (for example, consultation or laboratory report), and each document must be assigned a "type" and given a "name." Because accurate labeling and data entry are essential both to take advantage of the information retrieval capability of the system and to find anything once it is filed, the physicians must oversee and modify the categorization and manual input of key data elements. As a result, we often feel like data input drones."
"Several patients have asked a version of a question posed by a supportive, long-established patient: "Doctor, do you find you are spending more time interacting with the computer than with your patients?" For a while, the answer was clearly yes."
Study Design
Study Participants
The study participants include four physicians who are internists at the clinic.