SGIM Forum

Technology Update

Gaps in Care Due to a Scattered Electronic Medical Record

Dr. Ali ( is a second-year internal medicine resident at Stony Brook University Hospital.

Inefficient utilization of care is a major challenge in Medicine in the United States—an underemphasized facet is poor communication between electronic medical record (EMR) systems. While EMR adoption has expanded significantly, the ability to interoperate is limited in this billion-dollar industry, and information blocking continues to occur. There have been gradual improvements, including the government’s introduction of Meaningful Use Incentive Programs in 2009, renamed “Promoting Interoperability” in 2018. Born from this were Regional Health Information Organizations—local hubs to share and access patients’ health information electronically. However, holes and inaccuracies remain in EMRs. For example, it is particularly dangerous when you cannot determine a patient’s baseline health status, and cannot elicit what, when or where medical devices were placed. Inter-hospital record shares are formatted differently and accessed in a separate tab in most EMRs (including Epic’s Care Everywhere and Cerner’s Community View). A fax uploaded as a PDF cannot fully be integrated into the fabric of most EMRs, making that content unsearchable except manually. There is no mandate for this information to be in HTML format. While consensus on data formats and elements has improved, including via “Fast Health Interoperability Resource”—an application programming interface—there are still barriers to interoperability. The potential for innovation remains, including via Smart Health IT, a platform which allows innovators to create apps which can be used across health care systems. Furthermore, the Trusted Exchange Framework and Common Agreement (TEFCA) was released on April 19, 2019, and outlines “rules of the road” for nationwide electronic exchange across disparate networks. Additionally, the MyHealthEDataInitiative aims to break down barriers for patients’ access to their records.

I wonder if we, as patients, are inextricably tied to one health system. When we stray, it is common for there to be no medical record in sight at the time of care, or for it to be inaccurate or incomplete. We are surprised, upset and frustrated when providers do not know our stories, and vice versa. Furthermore, there is no national patient identifier. This leaves room for countless medical errors (especially in medication reconciliation), unnecessary testing, and delays in care. A single EMR is the obvious ideal however it has barely been discussed in American literature as it is not feasible—a frustrating realization that I encountered during my research. The barriers to this appealing idea include weak physician political advocacy, concerns regarding funding, fear of bureaucratic burden, stifling of innovation (as with Veterans Affairs use of Vista CPRS), and data security. Security concerns of a single EMR are likely blown out of proportion given that most security breaches in the United States have been phishing or hacks of third-party companies,1 and multi-factor authentication continues to be protective. Given these concerns, a single EMR will not see the light of day in the United States anytime soon.

Even if interoperability is realized, our EMRs still run on the paradigm of hand-written notes and dusty billing standards. Each note is a discrete entity with one author. Inaccurate statements or misspellings are propagated. According to a paper from 2016,2 saving physicians’ time and eliminating data duplication has been on the EMR to-do-list since 1992. This expectation has yet to be realized. Furthermore, the volume of data remains an issue. Computers are not smart enough to condense the health record to remove fluff that is no longer needed; however, strides are being made in natural language processing. Graphic User Interfaces (GUIs) are underutilized, and do not auto-populate to illustrate important graphic trends without extra clicking. Procedure lists and problem lists are not consistently updated by the proceduralist or diagnostician who should be held responsible. Searching and reviewing the EMR is increasingly time-consuming as one patient may have thousands of notes. It may be difficult to find information even within a single note (such as PT/OT discharge recommendation) and nursing task-based notes are tedious to read.

In 2018, CMS announced a “Patients Over Paperwork” initiative to reduce provider burden by simplifying documentation requirements (in 2019) and reforming the associated billing codes and physician fee schedule (to take effect in 2021). Additionally, to reduce redundancy in the medical record for established patients, certain elements (such as chief complaint and history) documented by allied health professionals can be used for billing. Of the five E/M codes, level 2 thru 4 will be reimbursed at a single rate, and require supporting documentation currently associated with level 2 visits. Additionally, policies and payments for advancing virtual care are being finalized, and recently accelerated, as Telehealth gained a spotlight during the COVID-19 pandemic.

It is indisputable that discrepancies in patient data result in gaps in care. We can fill these harmful gaps with more user-friendly EMR features, including a multidisciplinary “team-based note” and “medical timeline”. CMS admits that current documentation requirements may not account for the growing emphasis on team-based care. A team-based note should be considered as a method for optimizing team-based care. This note would allow multiple authors to edit a single note in real-time, with each contribution demarcated by provider name and timestamp. This would eliminate copy-forwarding, decrease time spent on chart review and documentation, allow consultants to focus on their areas of expertise, improve co-management of complex patients, and ease transitions of care. Additionally, a medical timeline would provide a bird’s-eye view of health history. Improving EMR accuracy could strengthen the therapeutic alliance, reduce physician burnout, and indirectly improve data analytic capabilities (OHDSI [Observational Health Data Sciences and Informatics] is currently tackling this).

Another challenge is the utter lack of integrated HIPAA-secure inter-provider communication. Microsoft Teams, paging apps, and EMR-based mobile chatting make communication easier, but none are fully integrated into the EMR. While participation in nation-wide physician networks such as Doximity is currently voluntary, it has the potential for expansion into a more widespread communication platform. It is scary that the lag in healthcare technology exists despite the risks to patient safety. We owe our attention to the field of Clinical Informatics— our main interface with the communication technology industry. Furthermore, why not borrow inspiration from other professional fields, such as banks and financial sectors, who utilize iris and facial recognition? How can we phase out our archaic use of pagers, fax machines, and burdensome record request processes?

As an American health care provider, I am dismayed by our medical record-keeping. In a perfect world, we would wear a concise medical summary on our wrists, and it would be easily and securely accessed by providers. In some countries, citizens already have medical smart cards.3 The European Union is on the brink of rolling out a multi-country EMR exchange—the first of its kind—called eHDSI (eHealth Digital Service Infrastructure),4 as recommended by the European Commission in February 2019.5 This large undertaking inspires hope that we can improve the U.S. EMR within the constraints of our system, and perhaps aspire to a unified EMR someday.


  1. Davis J. The 10 biggest data breaches of 2019, so far. HealthITSecurity. Published July 23, 2019. Accessed May 15, 2020.
  2. Evans R. Electronic health records: Then, now, and in the future. Yearb Med Inform. doi: 10.15265/IYS-2016-s006.
  3. Vezina K. Medical smart cards find their niche. MIT Tech Rvw. Published June 14, 2011. Accessed May 15, 2020.
  4. European Commission. Exchange of electronic health records across the EU. Updated April 1, 2020. Accessed May 15, 2020.
  5. European Commission. eHealth DSI Operations home. Published March 9, 2020. SGIMAccessed May 15, 2020.  


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