The full content of Annals is available to subscribers

Subscribe/Learn More  >
Ideas and Opinions |

Electronic Health Records: Design, Implementation, and Policy for Higher-Value Primary CareEHRs for Higher-Value Primary Care

Christine A. Sinsky, MD; John W. Beasley, MD; Greg E. Simmons, MA; and Richard J. Baron, MD
[+] Article, Author, and Disclosure Information

From Medical Associates Clinic and Health Plans, Dubuque, Iowa; University of Wisconsin School of Medicine and Public Health and MetaStar, Madison, Wisconsin; and American Board of Internal Medicine and ABIM Foundation, Philadelphia, Pennsylvania.

Disclaimer: Drs. Sinsky and Beasley and Mr. Simmons are members of the National Collaborative for Improving Primary Care Through Industrial and Systems Engineering (I-PrACTISE), but their views do not represent any formal policy statement from I-PrACTISE. Dr. Baron is CEO at the American Board of Internal Medicine (ABIM), but the views expressed here are not those of the ABIM.

Disclosures: None. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-2589.

Requests for Single Reprints: Christine A. Sinsky, MD, Medical Associates Clinic and Health Plans, Department of Internal Medicine, 1000 Langworthy Street, Dubuque, IA 52002; e-mail, csinsky1@mahealthcare.com.

Current Author Addresses: Dr. Sinsky: Medical Associates Clinic and Health Plans, Department of Internal Medicine, 1000 Langworthy Street, Dubuque, IA 52001.

Dr. Beasley: University of Wisconsin School of Medicine and Public Health, Departments of Family Medicine and Industrial and Systems Engineering, 1100 Delaplaine Court, Madison, WI 53715.

Mr. Simmons: MetaStar, 2909 Landmark Place, Madison, WI 53713.

Dr. Baron: American Board of Internal Medicine and ABIM Foundation, 510 Walnut Street, Suite 1700, Philadelphia, PA 19106.

Author Contributions: Conception and design: C.A. Sinsky, J.W. Beasley, G.E. Simmons.

Analysis and interpretation of the data: J.W. Beasley.

Drafting of the article: C.A. Sinsky, J.W. Beasley, G.E. Simmons, R.J. Baron.

Critical revision of the article for important intellectual content: C.A. Sinsky, J.W. Beasley, G.E. Simmons.

Final approval of the article: C.A. Sinsky, J.W. Beasley, G.E. Simmons.

Administrative, technical, or logistic support: J.W. Beasley, G.E. Simmons.

Collection and assembly of data: J.W. Beasley.

Ann Intern Med. 2014;160(10):727-728. doi:10.7326/M13-2589
Text Size: A A A

Use of electronic health records (EHRs) has grown over the past decade. The authors of this commentary believe that EHRs are inconsistently aligned with the needs of primary care patients and physicians. They propose a set of design, implementation, and policy principles for EHRs that support higher-value primary care.

First Page Preview

View Large
First page PDF preview





Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).


Submit a Comment/Letter
EHR - Not The Greatest
Posted on May 20, 2014
Emeritus, Nevada Heart Institute
Conflict of Interest: None Declared
My experience in observing physicians using the EHR has not been favorable or impressive. The physician sits with his back to the patient often, concentrates on pushing the buttons, and really fails to connect with the patient. I think the 'busy work' of inputting to the computer may so distract that important questions may be omitted.
I believe the big push for EHR has come from government. I believe that physicians functioned easier and patients communicated better with physicians who faced the patient, wrote notes while chatting with the patient, and were not trying to create an electronic record designed to fulfill government billing and information demands.
recurring themes
Posted on May 20, 2014
LaPorta, Mark A MD FACP
Mark A LaPorta, MD FACP
Conflict of Interest: None Declared
When it comes to EMR, why do I always feel like I'm being conned?
Well done!
Posted on May 28, 2014
Randy Dalbow, MD
Lady's Island Internal Medicine
Conflict of Interest: None Declared
This statement is very well written. It provides concise guidelines for the future development of an EMR that helps rather than hinders primary care physicians and their staff. Kudos to the authors.
Posted on June 6, 2014
Michael E. Miller, M.D.
Boston University Affiliated Physicians
Conflict of Interest: None Declared
I could not agree more with Sinsky and Beasley’s observations, premise, and proposed principles to support higher-value primary care through the Electronic Health Record.
My concern is that their recommendations come about 10 years too late! Where were the institutional leaders of primary care/internal medicine, promoting the author’s recommendations, when both first, and now second generation EHR’s were being designed and installed? The corporate axiom remains true: if you don’t have a seat at the table, you’ll find yourself on the menu. Organized medicine’s, particularly primary care’s strategy of reactive response (let’s see how commercially available EHR’s function, then we can make changes) as opposed to demanding pro-active involvement continues to leave us very weakly positioned to effect such changes. Leadership requires a change in this failed strategy.
My institution has just “gone live” with a new all-encompassing EHR after a year of preparation and representing a major financial investment, from a company that has now acquired a large, actually the largest share of the EHR market. It resembles our prior EHR, which was a constant source of frustration and aggravation, “on steroids”!
The author’s proposals face many real obstacles. With many practices and institutions already heavily invested in next generation EHR’s, where will their incentives be to buy new systems? The root of the problem for physician’s and their interests is that the primary purpose, design, and prime directive of the EHR, from its inception: the facilitation of transmission of clinically useful information, has been hijacked by the economically driven interests of, and advanced by the mutually beneficial alliance of institutional health care providers, as billers, and the insurance industry (as well as Medicare) financial interests as payors. Regrettably, there was no opposition from organized medicine. Current EHR’s still function primarily as a billing and payment, physician grading/”quality measure” collecting system. Where then, will be the EHR industry’s incentives to implement the author’s proposals. More importantly, where do the authors and their organizations/foundations find their leverage to implement their recommendations?
Primary care providers bear the brunt of the “pain” inflicted not only by the EHR, but also the major changes buffeting our once proud specialty of internal medicine. In my practice, the medical home is viewed as the repository of all information to be provided to: other (specialty) physicians, pre-op screening units, referral managers, network managers, health insurers, quality measurers, pharmacy benefit managers, prior authorizers, visiting nurses, home care providers, attending physician statements (APS) for life and long term care, disability adjudicators, college health services, and a cast of others. Providing this information invokes time and expense, none of which is compensated, except for the moment, preparing an APS. My medical home is not a happy one, especially after spending at least 3 hours every day after the last patient leaves on administrative chores of dubious value.
Primary care just doesn’t have the “juice” to enforce change. So, primary care physicians are changing, in substantial numbers, away from primary care. Tellingly, a cardiac surgeon I care for, and complain to, tells me that he and his colleagues “are so insulated” from the EHR that they barely take note of it. The orthopedic surgeons “can’t be bothered” with the EHR; they dictate their note or use a scribe. Some of our specialty colleague notes are so heavily templated and identical in appearance that I only read the concluding, usually brief assessment and plan, knowing that it is the only relevant information coming directly from them. The greater the encounter reimbursement, the less burdensome involvement with the EHR. Not a good position for primary care.
I appreciate the author’s efforts but it will take more than a declaration of principles to effect meaningful change. Sorely missing strong and dedicated leadership is essential. Unfortunately, I’m doubtful I’ll see it while I’m still practicing.
Author's Response
Posted on July 2, 2014
John W. Beasley, MD, Christine A. Sinsky, MD
Medical Associates Clinic
Conflict of Interest: None Declared
We appreciate the comments on our article,1 and join Dr. Miller in wishing we had written this ten years ago. EHRs were designed and implemented without a fundamental understanding of the real needs of primary care clinicians and staff, and without any systematic attempt to evaluate the impact on either patients or caregivers. An analogy can be made to introducing a new medication without an understanding of the cellular biology of the patients and with no attempt at post-marketing surveillance for effectiveness or side effects.

To understand the “basic science” of primary care and evaluate the impact of EHRs (some of which may be subtle and relate to factors such as break-in-task) input from physicians alone will not be sufficient, and outside expertise is needed. One attempt to do this is our collaboration between Industrial and Systems Engineers and Primary Care clinicians (https://www.fammed.wisc.edu/i-practise).

As our article, and Drs. Miller and Feld point out, the issues are not only technical and interface design but also derive from policy. Dr. Miller correctly notes that the fundamental purpose of EHRs may have been “hijacked”. We hope that a recognition of the problems caused by EHRs, as highlighted by the Rand-AMA study, 2 will bring the importance of these issues to organized medicine, payers and regulators. Fundamental philosophical changes to guide policy and implementation are needed 3 if we are to increase efficiency and reduce burnout --- which is in the interest of all.

We are in complete agreement with Dr. Feld about the need for clinicians to take responsibility for appropriate EHR use, and to use what limited evidence there is about patient interactions to guide their actions during encounters. 4 5 Again, this will require policy and organizational changes.

Our paper is a “call to action” for individual clinicians, organized medicine, health care organizations payers and policy makers – none of whom gain from the current dysfunctional system.

John W. Beasley, MD
Christine A. Sinsky, MD

1. Sinsky CA, Beasley JW, Simmons GE, Baron RJ. Electronic health records: design, implementation, and policy for higher-value primary care. Ann Intern Med. May 20 2014;160(10):727-728.
2. Friedberg MW, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy. . RAND Corporation;2013.
3. Howard PK. The Rule of Nobody. New York, NY 10110: W.W. Norton & Company; 2014.
4. Sinsky CA, Beasley JW. Texting while doctoring: a patient safety hazard. Ann Intern Med. Dec 3 2013;159(11):782-783.
5. Asan O, P DS, Montague E. More screen time, less face time - implications for EHR design. J Eval Clin Pract. May 19 2014.

Submit a Comment/Letter

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.


Buy Now for $32.00

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Related Articles
Topic Collections
PubMed Articles
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.