The EMR, and AI: Are they good? Pose risks? Both?

When I worked with residents in the hospital, the electronic medical record, EMR, was relatively new. We were fortunate to work in a hospital that invested heavily in a good, well-regarded EMR, and spent quite a bit on training the doctors to use it. In the end, almost all the “stakeholders” agreed on which one was best, and the hospital bought it, and had us trained. Good for them.

The EMR wasn’t perfect though. In addition, the hospital didn’t buy all the parts. EMRs come in modules, some necessary, some elective, especially back then. It was clear that the hospital had prioritized the modules for billing, and especially for maximizing billing. Also, anything that the subspecialists who earned the hospital lots of money wanted. Other modules, particularly those that would enhance primary care, were more rudimentary or absent. Some of the things that many of us thought would be easily facilitated by a computerized database and looked forward to having were not available. Surely, once everyone is loaded into the computer, it should be simple to print out a list of all the patients with diabetes assigned to a particular doctor! That would really help us to track them, contact them, make sure they didn’t fall through any cracks. Whoops, sorry, we didn’t buy that module. The maximization of potential billing, on the other hand, was not only there but required many different screens to be filled out, effectively transferring work to physicians from someone else.* And it was inconsistent in how it treated health risks. For example, tobacco use had a who series of questions, including information the patient themselves probably forgot about how much, when, etc., but there was only one on whether they drank alcohol.

There were many things that the EMR did make easier, though, including writing long notes in the chart, since people didn’t have to write by hand. Like the Word® program I am using, and most other computer programs, cut-and-paste became easy and routine. Residents’ notes got longer because they could cut-and-paste yesterday’s note and (hopefully) update it. But sometimes they might forget the update part; it could be embarrassing if yesterday’s note said “surgery tomorrow” and it still said it in today’s note, even though the surgery had occurred that morning! The EMR also facilitated making notes longer by importing all the lab results and radiology reports. This is important information, but it is also available elsewhere (i.e., in the lab and radiology sections). A simple “Radiology exams normal” or whatever they showed would have been much better than cutting and pasting the whole report, as well as briefer. Better because it would have required the resident to read it, make an assessment (“it’s normal”, or “it shows a tumor”) and write that. It would have required thinking. Not to say that they didn’t think, but a summary in their own words would have demonstrated that in a way that cut-and-paste couldn’t.

But the biggest problem with the EMR is the amount of time that it takes to complete, especially in outpatient clinic settings, and especially for primary care clinicians who usually have a wider variety of issues to address and less money to hire others (scribes, sometimes nurses or even NPs or PAs) to do their documentation for them. It is not uncommon for primary care physicians to spend more time documenting in the EMR, frequently at home at night**, than seeing the patient! And in the inpatient setting, hospitals hire nurses to comb charts looking for ways to “upcode”, to charge more.*** (A part of the ongoing contest between providers and insurers to see who can hit the other up for more (except when they have been vertically integrated, more common in outpatient settings, see Vertical Integration saves money. And CVS and its competitors use that to line their pockets, not provide healthcare, May 21, 2026). And potentially costing the patient more, if the insurer refuses to pay it all.

And now we have AI. Or AI is having us. The debate on AI, on whether it will create a great new world or a “Brave New World” à la Huxley, rages on, now with the Pope getting involved with a new 42,000 word encyclical. AI is happening, will continue to happen, and will continue to have effects, many untoward, and some of those resolving – but not necessarily in ways that are good for people. And there are many different people, not just in the US but in the world. Recent commentaries have suggested the benefit would be greatest for the well-off and well-educated (well, almost all things do), although what seem to be “regular” people are using it to bolster their “home brewed lawsuits” and clogging up courts (good or bad?)

I know a lot of doctors who are thrilled about AI, and see it as a vehicle for reversing, or at least slowing, the constant drain on their time that comes from more documentation being required for billing, for insurers, and even for government regulations, in some ways a counter-weight to the EMR. They have apps that record the entire encounter, and then AI drafts a progress note that covers all the essential information in the conversation for both clinical and legal/billing purposes. Then the clinician reviews, augments, and corrects the AI-generated note. Hopefully. That is a danger. AI (as well as clinicians, it should be noted) can make mistakes, and provide incorrect information. With people, we know who to blame. However, recent experiences with friends and family encounters with the health care system suggests that once something gets into the medical record, especially a digital one (indeed, all digital data collection), it is there forever and efforts to correct it do not always take.

And, back to the residents copying their notes rather than creating original ones, it is comparable (if more high-stakes than) to students using AI to write their papers. It allows the appearance of creation and completion without the thinking required to learn to do the job right. Of course, AI advocates argue that AI learns to think more reliably than do people. Maybe this is not a scary idea. A recent opinion piece in the New York Times by Dr. Helen Ouyang suggests that AI (ChatGPT, in this case) gives good, well-researched medical information, and, more important, is accessible to answer questions when the doctor isn’t. The author notes that ”Of course, as a doctor, I know when to question the chatbot and when to ignore it. Many other patients don’t.” That’s right, and that’s a concern. Most of us who have used AI know that it isn’t always right, but if it’s a topic we don’t know about, we don’t know.

The other thing that Dr. Ouyang liked about ChatGPT was, ironically, its personality, since “I had always assumed the ‘human side’ of medicine was the part A.I. couldn’t touch.” The AI was unflaggingly positive, upbeat and encouraging, and never got irritated about repeated or “stupid” questions. People miss this when dealing with – people. While some doctors, like other people, are not, by nature, always warm, positive or supportive, the circumstances in which they work, the pressure from their employers (see several previous pieces, recently Why is it so hard to get medical care? And what should we do about it?, March 15, 2026, and The problem with the US healthcare 'system': THE INSATIABLE PURSUIT OF EVER MORE MONEY BY CORPORATIONS AND WALL ST., Feb 25, 2026). We should also remember, that while being nice, and friendly, and supportive is usually good, it is also a strategy for gaining your trust that has been misused by bad actors throughout history. And AI never gets tired of doing it, never wants to go home, never misses its kids, and doesn’t have to worry about spending as much time completing the EMR as it did seeing you! (see Does AI communicate better than real doctors? If so, why is that?, Nov 20, 2025).

So, I guess that the jury is not in on AI, or its most effective and reliable and accurate utilization. When it is, it will probably be too late to change it.

  

*This is only one example of work that has been transferred to the primary user. I have long made my own travel arrangements, and like it because I know what I want, but it takes a lot of my time.

**Another example of work transferred to the clinician, at the expense of their family.

***See this piece for a clear example of widespread and profound upcoding: https://healthcareuncovered.substack.com/p/government-watchdog-agency-finds

EMRs and Primary Care: The good, the bad, and the challenges

One of the centerpieces of health reform as promulgated by almost everyone, and very much the Affordable Care Act (ACA) is the use of electronic medical records (EMR, also called, in a more inclusive formulation, electronic health records, or EHR). The Health Information Technology for Economic and Clinical Health Act (HITECH) specifically addresses specifications for EMRs. Demonstration of effective use of EMRs, including “e-prescribing” (in which prescriptions are routed electronically directly from the physician’s office to the patient’s pharmacy of choice), maintenance of patient registries (who in your practice has diabetes?) and compliance with a set of quality measures (What percent of the people in your practice with diabetes have had their sugar measured? What percent are in control?) account for a great deal of the added payment for chronic disease management, as well as payment for patient-centered medical homes (PCMH).

EMRs are a good thing for many reasons. At the simplest level, the fact that the records are on-line, rather than in paper charts, means that they don’t get “lost” and any doctor can see the notes of any other doctor. A number of years ago, prior to going to a real EMR, a large public hospital with many clinics where temporarily lost charts often meant that patient notes generated in one clinic visit were unavailable to another clinic, scanned literally millions of pages into a very basic EMR. While having none of the advantages described below, even this primitive method was a real step forward for them in being able to access the records. At their best, EMRs allow effective communication between doctors in a practice. For large multispecialty practices, this can also be between different specialists, and can even be integrated with the hospital’s medical record so that information from hospitalizations is immediately available in the same “chart”. The more that information is put in “digitally retrievable” format rather than free text, the more easily and thoroughly that a patient’s health trajectory can be understood. This is not only for numeric values, such as lab results and blood pressures that can be displayed on a flowsheet or graph, but even for history and physical items: Was that heart murmur present at the last visit? What is the history of the different medications that the patient has been on? Patient registries, as noted in the first paragraph, become an effective way of evaluating and improving the care given in the entire practice, not just for one patient, and are almost impossible without an EMR.

EMRs are not problem-free, however. The most common issue for physicians is that charting takes longer; filling in all this data takes time. This is worst when a new EMR is implemented, as old data has to be input (and this can even be when changing EMRs, not just going from paper, since of course they rarely “talk to” each other), but continues to be, on average, more time consuming than paper charting. In part, this may be because the notes are “more thorough”, or, looking at it the other way, that paper chart notes were inadequate. But it is also because the very structured nature of the EMR requires that a significant number of things be  entered/clicked (even to indicate “not applicable” or its digital equivalent) that would have appropriately not been mentioned in a paper note. Much of this added documentation goes beyond the information necessary to provide medical care for the patient, but is required to comply with government regulations and ensure that the document is “legally” sound. (It is a time long since the medical record existed solely as a reminder to the physician of what s/he had done for the patient in the past!) In addition, some of those regulations require the physician, as opposed to another health professional such as a nurse, to personally document certain items in the record, often to a degree that seems unreasonable to physicians.

There is an ironic turn to this. Most discussion in public policy circles is directed to increased inter-professional function and team work, as characterized by the patient-centered medical home. In part, this is because the current and projected shortage of primary care physicians means that there is no way that they, working alone, will be able to meet the health needs of the American people; if they are already working on a “hamster wheel” (see Family Medicine in the Era of Health Reform - 3, May 23, 2011), the changes described by Phillips (see Primary Care, Medical School Debt, and US Health Needs: Analysis from the Graham Center, May 30, 2011 ) and discussed in detail by Margolius and Bodenheimer[1], will increase the burden beyond any hope of sustainability. In addition, an effectively functioning team of health professionals (including nurses, pharmacists, social workers, and others[2]) makes for higher quality care. This is very clearly articulated in Dr. Atul Gawande’s recent address to the Harvard Medical School commencement, “Cowboys and Pit Crews” published on his New Yorker  blog. The irony is the increased requirements mentioned above, sometimes explicitly stated in law, but often in federal regulations and most commonly by Medicare “carriers” and interpreted by institutional compliance officers, have increased what the physician, him or herself, needs to document in the medical record (and, by implication, have actually done him or herself). These requirements both decrease effective team function, and increase the burden of electronic charting.

Thus, the ability of the EMR to record, and hopefully make retrievable, large amounts of data, raises the expectation that that data will be inputted, and also allows monitoring to ensure -- in the cases where lawyers or compliance officers have concern – which individual is doing it. In any new technology that increases the ease of accomplishing something, or the availability of a person or data, there is the corresponding tendency to expect it; this often has the ironic effect of increasing, rather than decreasing, workload. The internet and email allow us to work from home; cell phones, pagers, and email all increase our availability even when not at work or at home. This allows us more flexibility, but it has also led to the expectation of immediate access and, for many professionals including physicians, the virtual elimination of the concept of “work” versus “off” hours. The electronic medical record allows me to chart from home – or anywhere I can get an internet connection – and so I do.

The introduction of a new EMR, already a complex, difficult and daunting process, is also often used to change workflow, the processes by which the work of the practice is accomplished. This is virtually always a mistake, for providers and staff must now learn not only how to navigate and document in a new and strange systems, but to do things in a completely different way. The changes may be desirable, or they may not be, but certainly will require time and effort to identify whether they are, work it out, and “get it right”. Thus, it is greatly preferable to change that workflow prior to institution of the EMR (or if necessary after it is successfully adopted); the alternative is that learning new processes, especially when they are poorly conceived, gets lumped in with and blamed upon the EMR, increasing resistance to its adoption and potential benefits.

An interesting, and perhaps important, sidelight of the introduction of the EMR in our family medicine clinic was that the implementation team, composed of experts from the computer company and “superusers” of nurses from our group practice, saw how much more complicated the practice – and thus the documentation – is in primary care than in other specialties. In most sub-specialty practice, a few diagnoses -- and thus a few types of workflow and documentation strategies -- account for almost all visits, while in primary care the breadth of encounters (acute/chronic, prevention, adult/child/pregnancy, medical/psychosocial) in a single session, combined with the complexity of dealing with multiple chronic conditions based in a variety of organ systems rather than one, is actually breathtaking (see, for example, Primary Care: What takes so much time? And how are we paying for it?, May 21, 2010, "Uncomplicated" Primary Care?, Oct 8, 2009). Contrary to what they had been led to believe, they discovered that primary care was harder and more complex and more difficult to document – and of course required seeing more patients in shorter amounts of time for less reimbursement (which also leads to an ability to afford fewer support staff). This team, at least, gained a new respect for what primary care practice involves.

As we inevitably and inexorably move to reliance upon EMRs, we must be on guard to resist all the temptations to load every possible expectation upon them, and upon the providers who use them. They have enormous potential to not only increase quality but to increase teamwork and communication, and to even be labor-saving, but only if used wisely and judiciously.

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[1] Margolius D, Bodenheimer T, “Transforming primary care: from past practice to the practice of the future”, Health Aff (Millwood). 2010 May;29(5):779-84.

[2] Even, for example, lawyers. A number of practices, particularly in academic medical centers (including our family medicine clinic at KUMC) have legal partnerships where lawyers (often from Legal Aid) and law students help patients with legal problems they could not otherwise get help with, right in the clinic. It is amazing how often a person’s health improves when they no longer are as worried about their immigration status, getting evicted, receiving benefits, or the implications of divorce, among other issues.