Ambulatory EMR: Its No Longer Just About Inpatient Data
While an ambulatory EMR may help a practice reach financial incentives and streamline patient information, the initial rollout may be costly and negatively impact productivity.

Reducing errors

In 2009, slightly more than 600,000 ambulatory physicians were practicing in the U.S., but only 44 percent were using an ambulatory EMR. The use of ambulatory EMRs will continue to increase as the various deadlines to qualify for meaningful use incentives approach, ultimately reaching 89 percent utilization by 2016, according to a market research report released in August by Frost & Sullivan.

Some facilities, however, are ahead of the curve regarding the implementation of an ambulatory EMR. In an effort to improve patient safety and medication management, for example, the University of Texas (UT) Southwestern Medical Center in Dallas started an enterprise-wide EMR (Epic) adoption project in 2002. UT comprises more than four hospitals and 40 practices, and serves about 100,000 inpatients and 1.9 million outpatient visits annually.

Within the project, the facility also chose to implement an ambulatory EMR (Epic) to decrease the rate of medical errors and track and document performance drivers to optimize workflow, says Suresh Gunasekaran, assistant vice president and CIO of UT.

The expansion took almost four years to complete and cost $20 million for the entire package, including hardware, software, physician training, additional staff, a scheduling and registration system and a document-imaging system. Gunasekaran says it is worth it. The ambulatory EMR allows all physicians along the continuum of care to have a comprehensive view of the patient. Patient requests or questions are answered immediately, as nurses and physicians have their own inbox where patient prescriptions, refill requests and questions are listed. The EMR has reduced duplicate testing and helps physicians by documenting patient allergies and drug-to-drug interactions, and sending reminders to physicians about screening and other preventative health measures.

Making the transition smooth

Looking for a paradigm shift, Continuum Health Partners (CHP), a nonprofit health system that incorporates four New York hospitals—Beth Israel Medical Center, Roosevelt Hospital, St. Luke’s Hospital and the Long Island College Hospital—began an enterprise-wide ambulatory EMR project (eClinicalWorks) in 2009. The goal was to meet meaningful use goals, while providing better interoperability and lucidity to the facilities that have disparate systems.

The goal is for the EMR to be installed across 100 practices, reaching more than 1,000 providers in the local area in hopes to leverage patient care and quality across the community through health information exchanges. To date, 15 practices and 100 providers have been connected. Colleen M. Lyons, MBA, director of ambulatory support systems for CHP, says that collaboration with the business operations such as billing, as well as the clinical stakeholders—front desk to physicians—in each practice is crucial for an implementation to run smoothly.  

Her colleague, Andrew S. Kraatz, MBA, director of business transformation, says that executing a proper governance plan is important. “This is a culture change and has to be managed as such,” he says. Physician groups must understand why meaningful use standards are important and a goal of creating unified access to patient clinical data must play an integral part of EMR implementation.

“A high-level of governance with structured steering committees with tiered escalation and approval paths is imperative for creating a unified standard across the EMR system,” says Kraatz. “These interdisciplinary groups—work groups to executive steering committees—drive the standards and policy setting for the project and the use of the system being implemented.”

Another challenge for CHP was creating a balance between customization and standardization. The task is to tailor the systems to meet specific needs in various specialties, while still managing to maintain an enterprise-wide standard, says Lyons.

The UT team spent a good deal of time developing what they call “the best practice care model, because the EMR is more than a paper folder being put into a computer,” Gunasekaran says. “We needed the ambulatory EMR to map out the workflow across the practice.”

Both Lyons and Gunasekaran note that physician adoption was a major challenge. UT dedicated almost $500,000 for physician training, which began with eight hours of classroom lectures, in addition to hands-on training by IT staff at each clinic after a system went live.

For CHP, an initial IT EMR project team—comprised of a program manager, two implementation specialists and a project coordinator, along with three additional team members—attended intensive training courses and became super-users.

Lyons says, “The lesson we learned is to identify and request additional team members before a full rollout begins. We found our resources extremely stretched even during the pilot rollout. A lot of that has to do with the practices feeling the need to have more onsite support after go-live than was initially thought.”

Quality reporting

The Cardiovascular Group in Lynchburg, Va., part of Centra Health, began using an ambulatory EMR (GE Healthcare) three years ago to track and report cardiovascular data to the American College of Cardiology’s PINNACLE registry, which collects data from more than 500 outpatient practices to measure quality performance measures and benchmarks of cardiovascular care, including aspirin, statin, clopidogrel and beta-blocker use.

Initiated with a grant from the state of Virginia, Centra and The Cardiovascular Group began collecting and charting data of heart attack and unstable angina patients. In the first two years, the group spent $150,000 on the project, with an estimated 100 hours of physician time spent inputting/outputting data into and out of the registry.

The project’s aim was to evaluate whether or not care could be improved by marrying inpatient data with outpatient data, says C. Michael Valentine, MD, president of The Cardiovascular Group. “We wanted to know whether we could follow outpatients long term and keep better records on them. The ambulatory EMR is useful in identifying patients who may have stopped taking their medications or who have failed to meet certain goals, such as reaching optimal cholesterol or blood pressure levels.”

The ambulatory EMR electronically captures 113 clinical data elements from both the hospital and physician EMRs and are immediately available to the physician and sent to ACC for comparison with the best practice standards.

“At a patient’s follow-up visit, the ambulatory EMR prompts me to ask a recent MI patient whether he/she stopped smoking, is still on beta-blockers or clopidogrel or has been enrolled in a cardiac rehab program,” says Valentine. Documenting these specific data points and reporting to ACC creates a higher standard of care and competition, which ultimately has led to better long-term patient outcomes and a better standard of care, he notes.

At the Children’s Hospital & Medical Center of Omaha, an ambulatory EMR (Epic) spans across 40 dashboards and 10 general pediatric practices to collect real-time financial and clinical data to track productivity and clinical quality standards.

While one dashboard may solely monitor quality metrics such as asthma management plans, others may focus on tracking immunizations, smoking screening, attention deficit disorder or autism, says George E. Reynolds, CIO, CMIO and vice president of the facility.

The Children’s Hospital rolled out the ambulatory EMR into 10 practices—one every six weeks. However, Reynolds says the facility made a big mistake: not allocating enough resources for the practices that had rolled out the system first. “The implementation process took all of our resources and we didn’t have enough capital to circle back and ensure those early adopters were getting what they needed,” says Reynolds.

He says that the EMR also tracks whether doctors are working after hours or over the weekend to ensure that workloads are being properly distributed and resources are being properly utilized.

While more practices are looking to earn incentive money from the HITECH Act through EMR adoption, an ambulatory EMR can help to unify disparate technologies, connect inpatient/outpatient systems and, ultimately, advance patient care. Integrating an ambulatory EMR may be linked to initial cost and adoption challenges, but the benefits, which include consistency across multiple sites and quality tracking, can outweigh the impediments.