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Ambulatory Information Systems: The Last Frontier

September 26, 2011
by Pete Rivera
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It's Time for the Healthcare Industry to Provide EMR Support to Small Physician Groups

When I first started managing ambulatory information technology (IT) Systems, there was not much in the way of technology to manage. The hospital system that I was with had acquired a string of solo and multipractice offices and wanted to streamline its operations by installing a practice management (PM) system. The systems at the time were very straightforward. They had an electronic schedule that was not any more sophisticated than our current Outlook calendars and the PM system came with the ability to enter charges into an electronic HCFA 1500 claim form. Electronic claims were just starting to take off, and we spent most of our time testing with payers and migrating physician practices from a paper appointment book.

Over the years, ambulatory IT systems have evolved to include electronic claims scrubbers, eligibility verification, and more advanced billing and accounts receivable modules. Physicians eager to embrace the advancement in ambulatory technology began using electronic prescribing (eRX) and electronic medical records (EMR) in some limited form. The challenge at the time was how hospitals could offset the enormous cost for physicians, which often involved a lengthy return on investment (ROI) period. On the other hand, these hospitals could improve the quality of care by integrating their clinical systems with ambulatory clinical data and electronically capturing the entire continuum of care.



This of course changed when new Stark Laws allowed physicians affiliated with hospitals to offset some of the costs of an EMR. It seemed at the time that large hospitals and academic centers quickly began piloting EMRs with their physician's group, and vendors quickly began to fill the market with solutions. However, the dirty little secret about EMRs is that the core product is simply a notepad. Think of it as MS Word with scripts and tags that allow you to link templates or auto fill data. The real value and ROI comes from a consolidated electronic ambulatory record populated by all clinical ancillary systems and processes. These include computerized physician order entry (CPOE), eRX, e-Lab results, digital radiology, speech recognition, and electronic fax capabilities, just to name a few.


Early adopters had the deep pockets available, not only to tackle the challenges involved during the installation, but also to deal with the new support model that was required. Physicians, who once just had to worry about their staff sending the wrong bill to a patient, now had to worry about lab values getting posted to the wrong patient record.

Today we have government incentives through meaningful use (MU), which defines the goals of a “true” EMR, as well as certification processes like the Certification Commission for Health Information Technology (CCHIT). We also now have desktop hardware that is less expensive and provides more horsepower than previous generations of equipment. This has allowed ambulatory EMR vendors to pack more features that physicians are already demanding and that will be required if the software has to meet MU requirements. With DSL, cable, and fiber that can be used to reach out to remote physician offices, you now have the perfect set of technology convergence for the ambulatory market.


So why are there still many physicians groups that have not jumped on the EMR train? Because up until now the focus had been on physician groups affiliated with hospitals and academic medical centers. For the most part, the vast majorities of ambulatory physician practices have to find the EMR funding on their own, or try to take advantage of meaningful use dollars. However, even meaningful use dollars don't come close to fully funding the cost of the software. Most multipractice physicians groups (five to 10 physicians) are not prepared for the requirements of a complex clinical information system.

Again, you cannot tackle an EMR project without including the entire set of ancillary clinical information requirements. The data flow between the electronic record and the various interfaces requires proper network security and bandwidth, proper authentication, record matching criteria, uptime and data recovery, as well as the ability to export the data to electronic media (required to meet meaningful use). The IT resources that these physician practices rely upon for hardware or network support is normally a local computer shop not prepared for protected health information and security requirements. The Geek Squad in their VW bugs will not be able to handle the complexity of a clinical information system. Physicians are often at the mercy of vendors to guide them through purchasing decisions and support models.

For ambulatory practices that are already struggling financially, the other challenge lies with the productivity hit encountered during the EMR learning curve. This is another piece of information lost during EMR demos. Physicians cannot see the same number of patients or spend the same amount of time during their typical encounters when they are experiencing an EMR learning curve. Physician offices are often thrown into a complete tailspin when their workflow functions are dramatically changed. The office staff and physicians are quickly thrust into a new way of operating for which they may not have expected. Most vendors draw the line when it comes to helping with office workflow changes. They expect the physician practice to determine what works best in their unique scenario and how best to interface with their individual reference labs and ancillary services.

In the EMR world everything is customized, because of the variety of clinical care services provided, which encompasses primary care, complex specialty care, same day surgery, and other ancillary service inputs. Each practice comes with its own set of requirements, personalities, and eagerness to embrace change.


For small physician offices that are trying to meet meaningful use, there are some resources that exist through regional extension centers (REC). REC services include outreach and education, EMR support (working with vendors, helping choose a certified EMR system), and technical assistance in implementing healthcare IT. RECs focus on individual and small practices, including primary care providers, medical practices lacking resources to implement and maintain EMRs, as well as those who provide primary care services in public and critical access hospitals; and community health centers, and other settings that mostly serve those who lack adequate insurance coverage or medical care.

Other resources that are often overlooked by physician practices are local Healthcare Information and Management Systems Society (HIMSS) chapters. The Central/North Florida HIMSS chapter, for example, recently developed an ambulatory IT committee with the purpose of reaching out to the ambulatory market and assisting with the proliferation of healthcare information knowledge and guidance.

Currently, ambulatory IT is truly the last frontier for pushing out technology to the first point of care. There are many challenges in deploying a robust clinical system to small physician offices. However, the time has come for the healthcare IT industry to deliver seamless, cost effective solutions to this market and provide a framework for support for those that need it and for those that may not qualify for REC support. Physicians and staff not familiar with organizations like HIMSS and resources like Healthcare Informatics magazine need to be informed about how to tap into this knowledge base and receive proper guidance in a vendor-neutral environment.

Pete Rivera is consultant manager with Hayes Management Consulting, Newton Center, Mass., and a member of the Healthcare Informatics blogging team, who regularly comments on issues around electronic health record and physician management systems. Healthcare Informatics 2011 October;28(10):42-44

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