A new patient arrives at the doctor’s office having scheduled an appointment for a suspected urinary tract infection. After the clinician has assessed that issue and arrived at a plan of care, the patient says, “Oh, by the way, could you also take a look at this rash?”
That common scenario is one of several that HIMSS says office-based clinicians and practice managers should consider when implementing an electronic health record (EHR). Ease of documenting multi-complaint visits is just one of the many factors HIMSS considers important in an ambulatory EHR. Other factors include effectiveness of managing chronic conditions, ease and reliability of prescribing medication and renewing prescriptions, effectiveness of communicating lab and other test results, access to patient education materials, and more.
According to the Office of the National Coordinator for Health IT (ONC), use of electronic health records by physicians in office-based practices has more than doubled since 2008. Some 60 percent of office-based physicians, 20 percent of nurse practitioners, and 2 percent of physician assistants have demonstrated meaningful use of health IT as defined by the Centers for Medicare and Medicaid Services EHR Incentive Programs.
Moreover, as research grows into how EHRs affect quality and safety, evidence seems to be mounting that, when applied optimally, health IT can indeed contribute to improved outcomes and safer care.
Does that mean we have this figured out? Not by a long shot. As is the case with inpatient systems, ambulatory systems can introduce unintended consequences and add additional work to already overburdened clinicians.
Unique Challenges in Ambulatory EHRs
EHRs in ambulatory settings require a wide range of functionality, including patient-facing technologies, like portals or telemedicine, smartphone applications, outpatient pharmacy integration, and integration with other technologies, such as medical devices being used in the patient’s home. Interoperability is a huge issue because, ideally, these platforms should be communicating data to each other and putting together a coherent picture for the clinician.
According to Jonathan French, CPHIMS, Senior Director of Quality and Patient Safety Initiatives at HIMSS, ambulatory practices face different challenges with EHRs than inpatient settings. “One of the primary challenges is the lack of interoperability with local hospital systems,” said French. “The lack of the information in real time can serve as a barrier for providers to conduct the correct follow up.” French also noted that safety risks could stem from faulty clinical decision support, drug-to-drug and drug allergy alert fatigue, and the lack of IT expertise in many small ambulatory practices.
All of an EHR’s functions – e-prescribing, referral management, test result management, problem lists, medication lists, and documentation -- need to be optimized for the system to be as efficient and effective as possible. “The HIMSS Davies Awards program shares a significant number of use cases that can help providers optimizing these EHR functions,” said French.
More than likely, you have heard the story of the child who drew a picture of her visit to the doctor. The crayon rendering shows the girl on the exam table, interacting with her mother and sister, while the doctor turns his back to focus on a computer. EHRs can often add time and work to the clinician’s already heavy load, especially in primary care, taking time away from interaction with patients and contributing to burnout.
There are also challenges around change in general. As the ONC points out, we cannot simply layer an EHR onto existing practice routines. One study found physicians who are not fully utilizing their practices’ EHRs cited barriers including the need to change practice style; challenges to their autonomy; shift in expertise (with younger clinicians being more comfortable with technology); and required changes to interactions with patients. Recognizing these barriers may help practice leaders get ahead of them when designing workflows and implementing systems.
Certainly, many ambulatory practices have demonstrated impressive progress. For more than a decade, HIMSS has recognized health systems and practices that have improved outcomes through the use of health IT. Examples from the ambulatory setting include a primary care practice that reduced hospital readmissions by 10.5 percent, eventually yielding a readmission rate 50 percent below the national average. They did it by not only carefully selecting their system, but also taking the time to consider the workflow necessary to track thousands of patients. They also devoted time and resources — in the form of their own IT team — to adapt the system in a way that worked for their clinicians and staff and addressed their goals.
EHRs have great potential to improve the quality and safety of care, but it’s important to recognize that most ambulatory settings are still in the early stages. Next steps in the evolution of outpatient health IT include considerable work around interoperability, preventing unintended consequences, and making information easily accessible to patients and families.
Tejal K. Gandhi, MD, MPH, CPPS, is IHI’s Chief Clinical and Safety Officer.
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Free IHI/NPSF Webinar in collaboration with HIMSS - Information Technology and Improving Patient Safety in Ambulatory Care Settings (January 25, 2018 at 2-3pm EST, 1-2pm CST)