Ambulatory EMR: Tackling the Challenges

Although ambulatory EMR adoption may be difficult, having the correct balance of operational planning, realistic budget expectations, staff involvement and governance can help practices get through the trouble spots.

In spite of formidable up-front costs, integration issues and productivity hits, outpatient practices are embracing ambulatory EMRs. In fact, research firm Frost & Sullivan reported in August that the revenue in the ambulatory EMR market reached $1.3 billion in 2009, and it’s expected to double by 2012.

In 2009, 44 percent of the 614,000 ambulatory physicians practicing in the U.S. were using an ambulatory EMR, Frost & Sullivan found. As meaningful use deadlines hit, the firm projects that ambulatory EMR use will double, and that 89 percent of ambulatory physicians will use one by 2016.

Under the Health Information Technology for Economic and Clinical Health (HITECH) Act, as much as $27.3 billion could be doled out in incentive payments for meaningful use of electronic healthcare data via EMRs during the next 10 years, the Department of Health and Human Services (HHS) has reported.  

Although an ambulatory EMR can help a practice attain those financial incentives, the initial rollout is costly and can negatively impact workflow as well as patient volume, says George E. Reynolds, CIO, CMIO and vice president, of the Children’s Hospital & Medical Center of Omaha. Children’s began rolling out an ambulatory EMR in 2006.

Reynolds is not alone in this assessment. At the University of Texas (UT) Southwestern Medical Center in Dallas, ambulatory EMR deployment took almost four years to complete. It also soaked up $20 million in hardware, software, physician training, additional staff, a scheduling and registration system, and a document imaging system to scan paper documents into the electronic system, says Suresh Gunasekaran, assistant vice president and CIO of UT Southwestern Medical Center.

The academic medical center, which encompasses four hospitals and more than 40 practices, sees 1.9 million outpatient visits per year. UT started an enterprisewide EMR adoption project in 2002 and selected an ambulatory EMR from Epic. The impetus for deploying an EMR was a desire to decrease the rate of medical errors, streamline disparate electronic systems, and accurately track and document performance drivers and quality benchmarks to optimize workflow, says Gunasekaran.

The initial challenges were worth the final outcome—a more complete perspective of the patient, he says. “We have many different specialties—neurology, urology, neurosurgery, internal medicine, among others—and patients at different times may need to go between these specialties and see different specialists,” he says. “Really, the big driver for us was to have a comprehensive view of the patient so we could see every treatment, test and office visit.”

In addition, UT has realized a decrease in duplicate testing. “If a patient has been to three clinics in three months, the EMR can see whether the radiologist or lab has already ordered a test of lab as opposed to reordering it,” he says.
 

Worth the challenge?

Continuum Health Partners (CHP), a nonprofit hospital system that comprises four hospitals—Beth Israel Medical Center, Roosevelt Hospital, St. Luke’s Hospital and the Long Island College Hospital—began an enterprisewide ambulatory EMR project last fall to meet meaningful use goals while at the same time providing remote access for doctors and patients across various specialties, in hospital network that had many disparate systems. Like UT, CHP wanted a better overall picture of patient care and sought to optimize clinical workflow, communication and management, says Colleen M. Lyons, MBA, PMP, Ambulatory Support Systems at CHP.

When CHP’s ambulatory EMR project is complete, the eClinicalWorks ambulatory EMR will be installed in 100 practices and at more than 1,000 providers affiliated with CHP, to leverage quality improvement through local and regional health information exchanges (HIEs) with help of the New York state Department of Health, says Lyons.

Strong involvement from business and clinical stakeholders is crucial for an EMR implementation to run smoothly, Lyons says. In addition, says Andrew S. Kraatz, MBA, PMP, director of Business Transformation at CHP, a proper governance plan is vital, because “it is often difficult to get all the physicians across every hospital to agree on one single solution.”
 

Fitting the EMR to the workflow

Because the ambulatory EMR was deployed to so many practices, tailoring the system to meet specific needs of individuals in various specialties, while still managing to maintain an enterprisewide standard, was very difficult, says Lyons.

“We don’t get department-specific with multiple templates. Similar specialties across different hospitals decide on one set of common forms/templates so that there isn’t a duplication of effort. We also try to keep specific departmental information as least as uniform as possible [having assessments in the same place, problem lists] across the different specialties,” says Lyons.

University of Texas Southwestern Medical Center also faced major challenges in getting its ambulatory EMR to fit into the workflow. “We needed the ambulatory EMR to map out the whole workflow across the practice. We needed to decide and design the system by how we wanted to see and treat patients and how we move them through the clinic,” says Gunasekaran.

Physician adoption was another major challenge at UT and at CHP. “Physicians went to medical school to take care of patients. And while they were taught how to assess and diagnose patients, they weren’t taught necessarily how get information from a computer,” he says.

“It is very difficult to convince the provider that he or she has to reduce their patient volume for a few weeks because productivity will drop off during the initial go-live period,” Lyons agrees.

UT selected a physician champion at each practice, who was trained on the EMR and then worked with others in the practice. In addition, the physician champion helped to design the EMR and tailor it to each specialty so it wasn’t a generic system. The organization compensates dedicated EMR team physicians who tailor the ambulatory EMR and teach others; however, physicians are not compensated for participating on oversight committees of application training, Gunasekaran says.
 

The money question

Children’s Hospital & Medical Center opted to roll out its ambulatory EMR to 10 practices, one every six weeks. However, Reynolds says the facility made a big mistake by not allocating resources for the practices that rolled out the system first and subsequently needed more money for training.

“The implementation process took all of our resources and we didn’t have enough resources to circle back and ensure those early adopters were getting what they needed. It would have been better if we allocated resources for that in advance and spread them around,” he says. Reynolds declined to say how much Children’s spent on its EMR implementation.

UT dedicated almost $500,000 for physician training, which included eight hours of classroom instruction and hands-on training by IT staff at each clinic after a system went live. As a follow-up, e-learning modules were launched as web-based tools for physicians.

“It was difficult to figure out a way to train our physicians so that they felt comfortable with using the EMR … even this many years later, there are still physicians who struggle moving through the computer system,” says Gunasekaran.
 

Clear view from the dashboard

UT uses the ambulatory EMR to track whether providers are performing complete and comprehensive patient documentation. The EMR can track documentation history and patient orders and locate whether or not providers are documenting a note and signing their charts completely and in a timely fashion.

The Epic ambulatory EMR used by Children’s Hospital & Medical Center now spans 40 dashboards, and 10 general pediatric practices collect real-time financial and clinical data to track productivity and clinical quality standards, says Reynolds.

The system also tracks whether doctors are working after hours or over the weekend to ensure that workloads are being properly distributed or resources are being properly utilized, he says.

Deploying an ambulatory EMR may be linked to lofty costs and challenges, but benefits such as tracking quality data and performance measures, reducing unnecessary testing and avoiding medication errors outweigh these issues, according to outpatient practices that have lived to tell the tale.