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Creative Minds: Building a Better Electronic Health Record

Posted on by Dr. Francis Collins

Doctor with tablet

Stock photo

Is 5 too few and 40 too many? That’s one of many questions that researcher David Chan is asking about the clinical reminders embedded into those electronic health record (EHR) systems increasingly used at your doctor’s office or local hospital. Electronic reminders, which are similar to the popups that appear when installing software on your computer, flag items for healthcare professionals to consider when they are seeing patients. Depending on the type of reminder used in the EHR—and there are many types—these timely messages may range from a simple prompt to write a prescription to complex recommendations for follow-up testing and specialist referrals.

Chan became interested in this topic when he was a resident at Brigham and Women’s Hospital in Boston, where he experienced the challenges of seeing many patients and keeping up with a deluge of health information in a primary-care setting. He had to write prescriptions, schedule lab tests, manage chronic conditions, and follow up on suggested lifestyle changes, such as weight loss and smoking cessation. In many instances, he says electronic reminders eased his burden and facilitated his efforts to provide high quality care to patients.

Still, Chan was troubled by the lack of quantitative evidence that electronic reminders actually enable healthcare providers to provide better patient care, as well as by anecdotal evidence that too many electronic reminders may actually have a detrimental effect on care. Indeed, getting a better handle on the efficacy of electronic reminders is crucial as the US healthcare system continues its transition from paper to electronic health records. It’s been estimated that eight in 10 office-based physicians and six in 10 hospitals now use some type of EHR system, and that number continues to grow [1].

David Chan

David Chan

Now an assistant professor at Stanford School of Medicine, Palo Alto, CA and a physician-scientist with Veterans Affairs (VA) Palo Alto Health Care, Chan recently received an NIH Early Independence Award to explore the impact of EHR electronic reminders on the quality of primary care. His research will focus on the Veterans Health Administration (VHA), the country’s largest healthcare delivery system serving about 9 million enrollees at 150 hospitals and 819 community-based outpatient clinics. Because the VHA was among the first healthcare systems to adopt EHRs, it will provide Chan with an excellent window into the real-world experiences of doctors, nurses, and other healthcare professionals accustomed to working with electronic reminders.

Preliminary research by Chan shows that, depending upon the VHA facility, the same type of healthcare provider caring for the same type of patient may have to process as few as 5 or as many as 40 electronic reminders relating to preventive care and disease management. Building upon this work, Chan will study in greater detail how electronic reminders vary not only in number, but in topic breadth, complexity, and comprehensibility. Most importantly, he will analyze the impact of all of these factors upon the productivity and efficiency of healthcare professionals and the quality of care received by patients.

Such work is part of a much larger, ongoing NIH effort to generate the evidence base needed to guide the design, use, and evaluation of an ever-expanding array of health information technologies. For example, the recently announced Precision Medicine Initiative will enable volunteer participants to partner with researchers to develop creative new approaches for the gathering, use, and sharing of genomic, health, and lifestyle information via EHRs, mobile health devices, social media, and other electronic information platforms.


[1] Despite substantial progress in EHR adoption, health information exchange and patient engagement remain low in office settings. Furukawa MF, King J, Patel V, Hsiao CJ, Adler-Milstein J, Jha AK. Health Aff. 2014 Sep;33(9):1672-1679.


David Chan (Stanford School of Medicine, Palo Alto, CA)

NIH Director’s Early Independence Award Program

VA Palo Alto Health Care System

Precision Medicine Initiative (NIH) (US Department of Health and Human Services)

NIH Support: Common Fund


  • Laura Henze Russell says:

    These little things are very important. Thank you for paying attention to them. I have a small suggestion to make. When doing intake and on each visit, when you ask for a list of current Rx and OTCs, ask for a list of installed dental device materials. It is highly relevant. While installed medical devices will be in the patient’s EMR, in many cases their dental records will not be. Perhaps it is different in USPHS, VA, IHS and Medicaid. In too many cases, dental is a separate country, with a Chinese Wall between physicians and dentists, EMRs and EDRs. We need this information for all patients, all physicians, all ACOs, all payers, all insurers, all levels of govt, all Big Data. As new information has come out about genetic susceptibility to mercury toxicity from dental amalgam, this must be a consideration in the health and mental health status of every current and former enlisted person, and every American who has ever had amalgam. For safety, health, better outcomes, and lower health care costs, we need to elevate #PrecisionDevices as the highest priority equal with or above #PrecisionMedicine, because the lack of prescreening the individual for biocompatibility before device installation is quite possibly the largest single driver of inflammation and chronic diseases today.

    There is ample evidence in the peer reviewed literature, in the clinical evidence coming out of rapidly growing functional medicine and biologic dental practices today, across social media platforms, and across international efforts that including banning and restricting use of mercury dental amalgam. Somehow, federal agencies, Congress, and the mainstream media are not yet looking, listening or paying attention to this. They still call it silver fillings.

  • Cj says:

    I only allow information given to my personal physician: I sign nothing, ever.

  • Laura Henze Russell says:

    I put a note on the MA HiWay consent form that I wanted my dental records included in my electronic health record. They rejected it and said there could be no annotation and asked me to resign it. I will not. It is incomplete without it, and is littered with wastebasket diagnoses and wrong diagnoses from specialists, with scads of labs and Rx written. Fortunately, the functional medicine physician I private pay for figured out I had mercury poisoning, persistent Lyme and mold toxicity, all confirmed by labs, and I worked with this doctor, my primary physician and a biologic dentist to get healthy again. I am off a bucket of costly, often ineffective medications with side effects, and onto a nutritional supplement compounded for my genetic glitches.

  • John says:

    Yes, i totally agree with the title. if you make your mind creative, then only you can build creative ideas.

  • Arul says:

    Thanks for an information!!!

  • arulkumaran says:

    Thanks for the information!!!

  • Samuel says:

    5 – 40 seems to be a high number.

  • ms says:

    Thanks for this informative post.

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