Miller RH et al. 2004 "Physicians' use of electronic medical records: barriers and solutions."

Miller RH, Sim I. Physicians' use of electronic medical records: barriers and solutions. Health Aff 2004;23(2):116-126.
"The electronic medical record (EMR) is an enabling technology that allows physician practices to pursue more powerful quality improvement programs than is possible with paper-based records. However, achieving quality improvement through EMR use is neither low-cost nor easy. Based on a qualitative study of physician practices that had implemented an EMR, we found that quality improvement depends heavily on physicians' use of the EMR - and not paper - for most of their daily tasks. We identified key barriers to physicians' use of EMRs. We then suggest policy interventions to overcome these barriers, including providing work/practice support systems, improving electronic clinical data exchange, and providing financial rewards for quality improvement."
To "suggest policy interventions that can promote opportunities for and lower barriers to using EMRs for quality improvement."
Tools Used
Type Clinic
Primary care and specialty care
Small, medium and large
Other Information
"Organizations included nine large medical groups of more than seventy physicians each, eighteen solo/small-group practices of ten or fewer physicians, and three medium-size groups. Most of the small groups were primary care only, while eight of the large groups were multispecialty."
Type of Health IT
Electronic medical records (EMR)
Context or other IT in place
The context varied across practices.
Workflow-Related Findings
"Although most clinicians maintained electronic problem and allergy lists, physicians varied greatly in how they documented progress notes. Basic EMR users had their dictated notes transcribed and imported into the EMR, or they typed their own progress notes into unstructured text boxes. More advanced users typed data into templates (electronic forms) that included physical exam and documentation prompts. Basic use of the EMR improved the legibility and accessibility of progress notes and increased the availability of electronic problem and allergy lists. More advanced use of documentation templates led to greater opportunities for improving quality of care. For example, problem-specific templates (such as a sore throat template) with embedded prompts reminded clinicians to ask about particular symptoms, order particular tests and prescriptions, or perform preventive or disease management activities. Also, templates that help clinicians enter data in coded rather than free-text form facilitated more advanced computer-based decision support for such tasks as care coordination and chronic disease management."
"Basic use of electronic ordering typically consisted of physicians' typing in prescription orders, responding to drug interactions and drug allergy alerts, and printing out prescriptions... In large practices, basic ordering often also included electronic ordering of referrals and laboratory and radiology tests. More advanced ordering capabilities included additional decision support, electronic transmission of orders to pharmacies and laboratories, and better tracking of test-order status and test results, all of which can improve quality and decrease errors."
"Basic use of electronic messaging among providers improved the
availability, timeliness, and accuracy of messages and increased completeness of documentation, thus potentially reducing "dropped balls" and safety problems. Much less common was advanced messaging, which included messaging with outside providers (to improve care coordination) and with patients (to improve patient satisfaction and, potentially, patient self-care and compliance)."
"Over time, some practices - especially larger ones - used reporting capabilities more widely. For example, some practices generated reports to physicians on diabetic patients with hemoglobin A1C levels greater than 8 percent and on the percentage of a physician's patients having such levels."
"Interviewees reported that most physicians using EMRs spent more time per patient for a period of months or even years after EMR implementation. The increased time costs resulted in longer workdays or fewer patients seen, or both, during that initial period."
"Most respondents or their colleagues considered even highly regarded, industry-leading EMRs to be challenging to use because of the multiplicity of screens, options, and navigational aids. Problems with EMR usability -especially for documenting progress notes - caused physicians to spend extra work time to learn effective ways to use the EMR."
"Another barrier to EMR use was the lack of adequate electronic data exchange between the EMR and other clinical data systems (such as lab, radiology, and referral systems). Having parallel electronic and paper-based systems forced physicians to switch between systems, thereby slowing workflow, requiring more time to manually enter data from external systems, and increasing physicians' resistance to EMR use.... For example, physicians in nine of the eighteen solo/small-group practices we studied could not view any electronic lab results within their EMR, seventeen could not view hospital data, and nine had EMRs that could not exchange any data with their practice management system. Some labs or hospitals refused to set up data exchange; less often, the practice failed to make necessary programming changes in its own EMR because vendor or internal IT support was lacking. In contrast, larger groups tended to have in-house lab and practice management systems that exchanged data with their EMRs, and had the leverage to obtain the cooperation of hospitals and other external data producers for electronic data exchange."
"All practices used EMR viewing capabilities, which improve chart availability, data organization, and legibility. ...The amount of initially viewable data depended on efforts to type in existing paper-based medical record data and to electronically import data from lab, billing, and other systems."
"As patient data [available for viewing] accumulated over time, financial savings accrued from less staff time spent finding, pulling, and filing charts and less physician time spent locating information."
Study Design
Only postintervention (no control group)
Study Participants
Thirty physician organizations took part in the study, and 90 interviews were conducted with EMR managers and physician champions in 2000-2002. There was a mix of primary care and specialty clinics, although the authors indicated that they were focusing mainly on primary care physicians' EMR use.