The adoption of electronic health record (EHR) technology has been frustratingly slow, and the reasons for the slow pace aren’t insignificant. Cost is obvious, but resistance to change and examples of EHR failure are factors keeping physicians and hospitals on the sidelines. Federal stimulus dollars will help spur some groups into action, but the key to widespread adoption is the relationship between EHRs and quality care.  

According to recent reports in The New England Journal of Medicine, less than one in five US doctors and only 9% of American hospitals use EHR technology. Yet the surveys indicated physicians who made the switch agree that EHRs improve quality of care. So why haven’t more made the investment?

Although it is true that aspects of the healthcare system make it difficult to facilitate record sharing, it is equally true that EHRs contribute to consistently high-quality and cost-effective care. But perhaps the biggest challenge of all isn’t in the acute care, inpatient setting. Instead, the outpatient ambulatory environment could be the hardest area to implement EHRs. 

Outpatient vs. inpatient

It is critical to understand the distinct difference between implementing an inpatient EHR and an outpatient EHR. The principle purpose is similar—compile and store patients’ medical information and use it to monitor their health and improve outcomes. The environments, however, are different. In the inpatient arena, every exam room is basically the same, but outpatient environments are outfitted differently, and different environments dictate different workflows. 

“People like to think that what you do for the inpatient world will apply to the outpatient world, but it doesn’t. Data is collected differently,” said Barbara Klein, senior business development executive with Concordant, an IT services provider for physician practices, hospital systems, and payors. 

“An inpatient could stay for two days and have blood levels checked several times. That data will be reported in a finite way many times a day,” she continued. “In the ambulatory setting, a physician will see patients across their lifetime but may not see them for years. Recording that data and reporting on it in a longitudinal way over time is different than the inpatient setting.”

Think ahead

Despite the snail’s pace of EHR implementation, some organizations are ahead of the curve. Massachusetts-based Compass Medical, a multi-specialty, multi-site physician group established in 1993 and a Partners Community Healthcare affiliate, began its trek into the ambulatory EHR world in 2002. According to Jamie Barber, executive director, the benefits of the system are many. 

“It allows physicians to be more proactive in terms of their ability to aid not just in treating the patient when they are there but also in prevention,” he said. “That is true healthcare as opposed to sick care.”

The problems hampering the transition from paper to a digital world can only be overcome if organizations anticipate them. Primary care physicians need a high volume of patients to succeed, but during the initial phases of EHR implementation, productivity will suffer. It takes time for organizations to shift their workflows. Patient registries need to be established and must be able to differentiate between patients with the same chronic illness who need varying levels of care. And then there is funding.

“One of the first things we do with organizations is help them understand the implications of the budget they have for the project,” Klein said. “They need to understand the true cost—not just what the software licenses, support, and hardware cost. There are many more costs that occur over the lifecycle of these projects and organizations that don’t consider that upfront could end up with a failed implementation.”

Don’t go it alone

When Compass Medical first invested in its EHR in 2002, it may have been ahead of its time, but it was also sailing through the fog. The company invested in GE’s Centricity electronic health record and essentially tried to manage the implementation on its own. However, it didn’t fully anticipate the amount of technical expertise and support that was necessary. In addition, Compass Medical’s EHR mission began before things like pay for performance and quality outcomes were a clear part of healthcare reform.

“The challenge of having to interface things like a lab information system, a practice management system, and a PACS is where the real stumbling blocks come,” said Barber. “In retrospect, we managed to do a good job of getting the entire organization up and running on the Centricity platform in less than two years.”

Compass was able to do this because it recognized the most fundamental truth about EHR implementation. Any organization looking to embark on this trail has to be prepared to deal with the pain, stress, and hit to productivity it will initially experience and accept that these challenges may last a few months. 

As a physician-owned company, Compass Medical had a tight-knit group committed to making the transition work. In fact, the implementation was so successful that in 2004, the company won the Nesson Award for Innovation from Partners for its EHR initiative. But the company also realized it needed help, which is when Concordant came into the picture. 

In the fall of 2007, Compass opened a 70,000-square-foot flagship facility, and its entire IT infrastructure was physically moved. It had outdated systems and servers out of warrantee and beyond their maintenance life. The company sat down with Concordant and talked about the sustained growth it had experienced in recent years and where the company felt it was going.

Concordant created a comprehensive report on what Compass needed to do to build a scalable, reliable system that could be readily enhanced in the future and was supported with disaster recovery backups. The analysis took into account the company’s HR needs, which for Compass Medical consists of eight IT resources split into two teams.

“A company like Concordant can really help you take into account all the resources, funding, and HR support you need,” Barber said.

There are other considerations as well. Security measures are key, with features like patient portals and online scheduling making information more vulnerable. Interoperability between providers will eliminate inefficiencies related to testing redundancy and poor communication when a community provider refers patients to an academic or tertiary setting. For EHR adoption to truly take off, the healthcare system must eliminate roadblocks, but physicians and hospitals willing to make the switch now can get a head start on the competition if they’re also willing to accept the inherent difficulties that remain in EHR implementation. 

“It is important to embrace the complex nature of ambulatory offices and the needs of physicians to help them successfully adopt the technology,” said Klein. “Looking back and learning lessons from early adopters can help do that.” 

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