Now Reading: Electronic Health Records in Ambulatory Care — A National Survey of Physicians

Electronic Health Records in Ambulatory Care

DesRoches, Catherine M., Eric G. Campbell, Sowmya R. Rao, Karen Donelan, Timothy G. Ferris, Ashish Jha, et al. “Electronic Health Records in Ambulatory Care — A National Survey of Physicians.” N Engl J Med (June 18, 2008). Electronic Health Records in Ambulatory Care — A National Survey of Physicians.

This is an informative study of electronic health record penetration by the group at Massachusetts General Hospital, funded by the Office of the National Coordinator.

The news? Not very good. Only 4 % of physicians have “fully functional electronic record systems.” The numbers are even more concerning if you look at small practices, where the overwhelming majority of Americans receive care: 2 % in practices with 1-3 physicians. In other words, most American physicians use paper based medical records.

There are a few (among several) very good things that this research group has done:

  1. They have defined what is meant by “electronic health record” so we can track this over time
  2. They have found that there was NOT a difference in rates of adoption among providers serving minority patients, uninsured patients, or patients on Medicaid

With that in mind, here’s the hope that this brings:

  1. If we’re able to define what physician access to an electronic medical record is, let’s now define what patient access to that same electronic medical record is.
  2. Let’s begin to use that metric as a complement to, or instead of the physician access metric. In other words, the EHR is not really implemented unless the patients can access the data in it to manage their health and participate in their care.
  3. Let’s be excited about the fact that with adoption on par among providers serving the uninsured, minority, and patients on Medicaid, that patient access to the data can become as standard for these patients, as they may become for commercially insured patients.

On the topic of the “patient access” metric – I don’t think we currently have a good definition. One organization might say, “We have x-thousand patients accessing their clinical information through a portal.” Another might say, “We have x-percent penetration of our patient base accessing a portal with their clinical information.” Yet another might say, “X-percent of chronically ill patients are accessing a PHR that contains their claim data.”

Not to bring up the “c”-word (crowdsourcing), but maybe we should get together to figure out what patients consider “access to data that allows them to fully participate in their care.”

In the meantime, thanks to the team at Mass General and ONC for tracking the physician side of things – great work as always.


It is interesting that the discussion remains in many ways focused on "the box" – the tool, rather than the larger issues of how we organize to provide care. This is another study that demonstrates that the organization of care delivery in America is fundamentally flawed. In addition the the lag in adoption of EHRs by small practices, we can add studies of quality of care to the data that demonstrate that it is not feasible to provide high quality affordable care if the model is the small business owner. While there exist a small number of very innovative small practices (the barriers to innovation are often lower in small practices), there is not a scalable spread strategy.

As an optimist, I have always hoped that incentives for EHR adoption would be structured to help physician practices merge to help them get to the next level of medicine's Mazlo's hierarchy of needs – past food and shelter (billing and revenue) and on to quality and affordability.

One more thing…Alex Sicre reminded me that at least one group of physicians is trying to go a different way, by starting HelloHealth. They've got a very patient-centered approach down to the EHR they've developed – how will that manifest itself or change the broader healthcare (specialty, hospital) community where they work – it's worth watching,


Regarding your comment:

'maybe we should get together to figure out what patients consider “access to data that allows them to fully participate in their care.”'

Where can patient portal or PHR managers discuss this important question? Suggestions?


Why don't we do it right here on this blog – it's as good a place as any. I will create a new post to start the conversation. Thanks for being interested in this question, it means to me that there are organizations that want to compete on involving patients and families in their care,


The management of medical transcription, medicare billing, and other medical records has typically consisted of wall to wall files of paper records. According to a recent survey conducted by Accenture, most health care consumers feel that switching to the electronic medical record would improve the quality of health care and the security of their records.But, most of the physicians said that they are not good.Because, sometimes the numerical errors may happened.

One interesting facet about Hello Health is that everything from Day 1 will be electronic, patient and MD driven. With Dr. Parkinson's solo practice, he has no office, only the charts on his server, which (I believe) his patients can access. From my understanding, his hope is to build out their first HH practice to serve 5K patients, then roll it out as a franchise.

They do not take insurance, so the patient really has a financial stake in their own healthcare, and the transparent technology supporting it. As you saw in the Myca demo, the MD really has a great tool and UI to review each patient's chart anywhere at any time. My PCP pulls out his old paper file, reviews the last few visits, discusses everything, makes more pencil scribbles, then I am on my way, with no way to follow-up on the care we have determined!

I assume HH falls into a type of concierge practice that not everyone can afford, but down the line the same technology can be adopted for larger practices that will reduce the costs? Or an insurer can adopt the platform as well? I don't know all the specifics, but it will be interesting to see how a small practice with a lot of press can change the industry.

Ted Eytan, MD