How to successfully select and implement electronic health records (EHR) in small ambulatory practice settings
A review of the article by Lorenzi et al., How to Successfully Select and Implement EHR in Small Ambulatory Practices Settings 
The authors in this article contend that adoption of EHRs in ambulatory settings has been slower than adoption in large patient settings. The scope of the article was twofold. First, to present an overview of the benefits and barriers for small ambulatory practices of 5 practitioners or less. Second, to provide EHR implementation recommendation for small ambulatory settings.
The researchers reviewed a study from 2006 which showed, the rate of use of information systems for clinical care in small physician practices in the U.S. was estimated between 14% - 25%. They also reviewed a national survey of 2,758 physicians from 2007-2008 that showed 4% of those physicians had a fully functional EHR and 13% had a basic system in place. A survey by HIMSS in 2005 found 17% of hospitals had a fully integrated EHR.. Some researchers believe surveys of inpatient use of EHRs were of mid to low quality because the studies did not differentiate between inpatient and outpatient use when surveying hospital based MDs. These surveys focused primarily on CPOE which is only a part of the EHR. 
There are similarities between both settings which are conducive to the benefits of EHR such as real time access to accurate patient information as a benefit to the continuum of care among disciplines. The article identified one major impact on the rate of EHR adoption between the two was due to the size difference, which made adoption in smaller venues extremely costly and for some small practices cost prohibited. The authors of this paper focused on benefits and barriers to using EHRs in small ambulatory practices and provided recommendations on how for successfully EHR implementation.
The identified benefits of EHR implementation in ambulatory practices included:
- Improved patient care
- Improved office efficiency
- Financial benefits related better coding, billing and decrease in inefficiency
The major identified barriers to EHR implementation in small settings included:
- Infrastructure and startup costs
- Variation in EHR products and design of vendor systems for small scale operations
- Resistance to change and lack of a flexible change management strategy for the staff to manage change
- Initial difficulty of system use leading to productivity reduction
- Perceived accrual of benefits to society and payers rather than to the providers
- Lack of a strong advocate or champion
The authors recommended EHRs be implemented with the advocacy of a champion and in the stages of decision, selection, pre-implementation, implementation, and post-implementation. Other key recommendations included assessing and redesigning workflow, understanding financial issues, conducting well-timed training that meets the needs of the staff and have a thorough plan for evaluating the implementation process.
It was recommended small physician practices be realistic and practical in determining their needs. Leadership should create the vision for the need for the EHR and for the desired changes to come with EHR implementation. The authors not ed several factors are relevant in successful EHR implementation including the technology, training, leadership, the change management process, the individual character of each practice and the organizational culture.  In addition, the authors recommended small practices: 
- Take the time to understand and investigate what an electronic health record can do for them specifically
- Decide which system to buy based on practice needs and regulatory requirements
- Ensure provision for training and continuous monitoring and technical support for the system
- Evaluate the readiness and eagerness of staff with an understanding of the need for people based skills and staff buy-in
- Identification and availability of a champion
- Determine the perceived usefulness of the EHR and teamwork.
The article did not address policy implications of EHR implementations or issues related to the interface of practice-based records to external information systems. The authors acknowledged additional research is needed to address these issues and to future refine recommendations for the small ambulatory practice.
- Lorenzi, N. M., Kouroubali, A., Detmer, D. E., & Bloomrosen, M. (2009). How to successfully select and implement electronic health records (EHR) in small ambulatory practice settings. BMC Medical Informatics and Decision Making, 9, 15. http://doi.org/10.1186/1472-6947-9-15.
- HIMSS, 2005. Sixteenth Annual HIMSS leadership Survey, Healthcare CIO Results: Final Report. Chicago: Superior Consultant Company/ACS Healthcare Solutions.
- Healthcare Information and Management Systems Society - content.healthaffairs.org) How common are electronic health records in the US. A summary of evidence. http://content.healthaffairs.org/content/25/6/w496.full.html.