How to successfully select and implement electronic health records (EHR) in small ambulatory practice settings

Introduction

The authors contend 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. Background The researchers determined that in 2006, the rate of use of information systems for clinical care in small physician practices in the U.S. was estimated between 14% - 25%. During 2007–2008 a national survey of 2,758 physicians determined 4% of physicians had a fully functional EHR and 13% had a basic system in place. A survey by HIMSS in 2005 found 17% hospitals had a fully integrated EHR. (2) (Healthcare Information and Management Systems Society - content.healthaffairs.org) How common are electronic health records in the US.A summary of evidence. Some researchers determined 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.(1) These surveys focused primarily on CPOE which is only a part of the EHR. (1) There are similarities between both settings which are conducive to the benefits of EHR. The authors note a major difference in the rate of adoption between the two is due to the scale or size difference. Real time access to accurate patient information is one great benefit of the EHR to the continuum of care as patient move from inpatient to outpatient care. The authors of this paper focused the benefits and barriers to using EHRs in small ambulatory practices and provide recommendations on how to successfully implement EHR implementation. Discussion The article identified benefits of EHRs in ambulatory practices include improved patient care, office efficiency, and potential financial benefits. Identified barriers to EHR implementation in small settings include: • Infrastructure and startup costs • Variation in EHR products and design of vendor systems • Resistance to change and lack of a flexible change management strategy when introducing EHRs to help staff 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 It is recommended EHRs be implemented with the advocacy of a champion in the stages of decision, selection, pre-implementation, implementation, and post-implementation. Other key elements include assessing and redesigning workflow; understanding financial issues; conducting training that is well-timed and meets the needs of practice staff; and evaluating the implementation process. Conclusion The authors recommend small physician practices be realistic and practical in determining their needs. Leadership must create the vision for the need for the EHR and for the ultimate changes to come with EHR implementation. The authors noted several factors are relevant in successful EHR implementation including the technology, training, leadership, the change management process, the individual character of each practice environment 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 personnel 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.