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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