EHR implementation in the ambulatory or hospital setting

Adoption of electronic health records (EHR) systems remains a challenge, both for hospitals as well as for physicians in ambulatory practice. The process of adoption, implementation, and meaningful use of EHRs (let us keep in mind) is actually quite different between those two setting.

Much has been written concerning EHR adoption within hospitals. Much of the experience in computerized physician order entry (CPOE) comes from hospital EHR adoption, and many of the concerns about poor EHR design and down-side (including actual patient harm) also come from the hospital experience.

A recent article in HealthLeaders Media describes “5 ways to boost physician acceptance of EHRs.” The focus is entirely on taking steps to facilitate EHR implementation in a hospital setting. The steps identified are quite valid, and worth understanding:

1. Identify physician champions
2. Design a training program that accounts for varying needs
3. Make “super-users” available during go-live
4. Allow providers extra time during go-live
5. Provide special amenities to take the pain out of launching the software

These are all very good points. It is important to put them into the context of their environment, however. Hospital implementation of an EHR is a decision made by the hospital administrative process, and physicians are expected to accede. The selection process is often by committee, with request for proposals (RFPs) put out to a variety of vendors, followed by invited demos from a short-list of interested vendors. Once the final decision is made, and contracts are signed, the hospital then uses IT staff to set up the equipment needed (servers, workstations, etc.), and the software is installed. Physician champions often emerge from this process (likely, physicians involved in the EHR selection committee), and are the early “test users” of the new system. Then there is the process of getting everyone on the medical staff (and all the hospital employees) to accept and use the new system.

This is a very different dynamic than the EHR selection process for ambulatory practices – particularly for small-group and solo practices. First of all, the systems being considered are different – they are not the massive things implemented within a hospital, designed to address all the myriad workflows in the complex hospital ecosystem (although hospitals have been known to try to push out their in-house products onto local community physicians, believing they are doing a favor). The kinds of EHRs that ambulatory practices need are smaller, more lightweight and nimble. The workflows and issues within a hospital are not the ones encountered in the doctor’s office.

Further, in an ambulatory setting, the doctor (or a designated “computer champion” within a group) often makes the selection decision. It does not go through committee, it generally does not involve a formal RFP process, and the timeline between decision and implementation can be much shorter.

The difference in the EHR implementation process described as “best practices” for hospitals, and the process for ambulatory physicians is most dramatically seen with a web-based EHR. A web-based EHR can be implemented on the very same day the decision has been made, and does not even require outside consultants to come in to the practice to set anything up (assuming that the practice can implement simple web-connected computers). Self-service implementation has revolutionized this process for small practices.

As a result of this, EHR adoption of these kinds of systems has taken off dramatically.

Given the magnitude of complexity that exists in the hospital ecosystem, the corresponding complexity (and cost) of the EHRs being sought by them is different altogether. And the risk to the hospital of choosing one that just doesn’t pan-out is significant. Consequently, lessons from that experience really have little relevance to the process that ambulatory physician practices (especially the small-group and solo practice end of the spectrum) use. With web-based EHRs designed for ambulatory care, the landscape is fundamentally changed.

Robert Rowley is a family physician and CMO of Practice Fusion.  He blogs at EHR Bloggers.

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  • Anthony Subbiah

    Good points Doc; yes, with the advent of nimble, customizable, web based EHRs, the landscape is changing and we see more adaptation. And yes; in the ambulatory care setting, decision making is by the provider(s).
    The implementation and training depends on the priorities set forth by the decision maker. And many a time, EHR vendor also needs to get the buy-in from the admin staff, especially the back office/billing staff. In a comprehensive EHR with billing and financial module, the provider, invariably wants to make sure the cash flow is not affected and likes to have the buy-in from his/her staff responsible for billing.
    And yes; provide more time to train the physicians at their own pace; rest of the staff can make up for upto 75% of the entries in the EHR including Demographics, Histories, etc. Its best to facilitate the Providers to slide into the system over a 60 day period as opposed to a big bang ‘cut-over’ approach.

  • Molly Ciliberti, RN

    First I think we all (and I do mean all) need to decide if it is EHR for Electronic Health Record or EMR for Electronic Medical Record, since both are bandied about and I think are interchangeable. Part of the problem with EMRs is that they take too much time to learn and to get up to speed in order to be productive. The companies that make them do not seem to have enough real life experiences in the trenches to understand work flow and documentation requirements. Most of them stink on many levels. I would advise anyone contemplating purchasing one to make a field trip to see it in action live and in color. Don’t just talk to the guy who made the decision and loves it; talk to the nay sayers too. I spent over 13 years in the business and have seen the good (rare), the bad (quite a few) and the ugly (most).

  • horseshrink

    I believe the best catalyst for EHR evolution and cost reduction is standardization of data constructs.

    If docs can change products at will, without the pain of database migration, EHR developers that want to remain in the market will become very interested in what docs actually want.

    As it is, right now, buying an EHR marries vendor and client via the proprietary database.

    Data migration cost + new product cost = very painful divorce

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