The authors review five key design elements of pay-for-performance programs that are important determinants of their influence:

1. deciding on an individual vs. group focus for payment;
2. paying the right amount;
3. selecting high-impact performance measures;
4. having payments reward all high-quality care; and
5. making quality improvement for underserved populations a priority.

An electronic medical record might include:

• Patient demographics.
• Medical history, examination and progress reports of health and illnesses.
• Medicine and allergy lists, and immunization status.
• Laboratory test results.
• Radiology images (X-rays, CTs, MRIs, etc.)
• Photographs, from endoscopy or laparoscopy or clinical photographs.
• Medication information, including side-effects and interactions.
• Evidence-based recommendations for specific medical conditions
• A record of appointments and other reminders.
• Billing records.
• Advanced directives, living wills, and health powers of attorney

Advantages of electronic medical records over paper records

A medical record includes any of an individual’s health documents of the types listed above. Medical records may be on “physical” media such as film (x-rays), paper (notes), or photographs, often of different sizes and shapes. Physical storage of documents is problematic, as not all document types fit in the same size folders or storage spaces.

Physical records usually require significant amounts of space to store them. When physical records are no longer maintained, the large amounts of storage space are no longer required. Paper, film, and other expensive physical media usage (and therefore cost) is also reduced with electronic record storage.

When paper records are stored in different locations, furthermore, collecting and transporting them to a single location for review by a healthcare provider is time-consuming. When paper (or other types of) records are required in multiple locations, copying, faxing, and transporting costs are significant.

In 2004, an estimate was made that 1 in 7 hospitalizations occurred when medical records were not available. Additionally, 1 in 5 lab tests were repeated because results were not available at the point of care. Electronic medical records are estimated to improve efficiency by 6% per year, and the monthly cost of an EMR is offset by the cost of only a few unnecessary tests or admissions.

Handwritten paper medical records can be associated with poor legibility, which can contribute to medical errors.. Pre-printed forms, the standardization of abbreviations, and standards for penmanship were encouraged to improve reliability of paper medical records. Electronic records help with the standardization of forms, terminology and abbreviations, and data input.

Electronic records keeping and order entry were found to reduce errors associated with handwritten documents and were recommended for widespread adoption.