Viewpoint: Continuity of care IS the electronic health record

March 1, 2009

Discussion of the importance of the eMR

All those very important components of health and illness were in my father's head as a result of his daily interactions with his patients and their families in our town, his visits to their homes when they were sick, his patronage of their businesses, and the consistency with which the medical care for his patients was provided only by him.

No one "took call" for him on weekends or at any other time, and there were no hospitalists to see his patients if they were admitted to our single local hospital. The price he (and our family) paid for this remarkable continuity of care was high-Dad was never home after supper or on weekends, because he was always visiting patients at the hospital or making house calls-but there was no question that he knew his patients, their medical problems, and their lives.

Most newly trained pediatricians evaluate prospective employment using criteria that include number of days worked per week (it's never 7), number of weekend calls per month, and level of support from physician extenders. This is not to say that today's pediatricians are not dedicated and caring, but neither they nor their families are likely to tolerate the commitment of time and energy that was expected of physicians in the past.

A major reason-though certainly not the only one-for the development of a comprehensive, accurate, and transmittable medical record is the loss of the continuity that was provided by solo or small medical practices whose patients sought care only at one site, and from a very limited number of providers. I suspect that one of the reasons for the reluctance of both the medical profession and the public to accept the concept of an electronic medical record (eMR) that is potentially accessible to multiple medical providers across the country is that we hang on to the notion that one physician should be the central repository for all information that pertains to the health and illnesses of an individual. Even as we endorse the medical home, however, we must acknowledge that patients will be referred to multiple providers and may seek care on their own from others, in their local communities, and across the country.

Our patients and children now store their personal lives electronically using social networking Web sites, and businesses and professional organizations have seen the benefits of an electronic presence that can be accessed and shared by members and by patrons. Similarly, pediatricians and the rest of the medical community will have to accept the fact that the complexity of today's medical care combined with the lifestyle expectations of health care providers make it impossible to accumulate the information needed for comprehensive, continuous, and complete medical care in a physician's head or a physical paper chart. In the 21st century, true continuity can exist only in cyberspace.

Dr. McMillan, editor-in-chief of Contemporary Pediatrics, is professor of pediatrics, vice chair for pediatric education, and director of the pediatric residency training program, Johns Hopkins University School of Medicine, Baltimore.