Ambulatory EHR vs. Hospital EHR

As the use of Electronic Health Records (EHR) systems matures, the difference in what is expected of hospital-based systems and those used by clinicians in ambulatory practices becomes more evident.

Ambulatory EHRs, like Practice Fusion, address the workflows found in doctors’ offices – and these workflows do vary (sometimes significantly) from one specialty to another. The Stage 1 criteria for Meaningful Use describe some fundamental elements needed for such systems, but the main thrust is to get physicians used to implementing computers (rather than paper) in their day-to-day work.

Ambulatory practices are “service nodes” in a larger ecosystem. Much of the work is done in concert with other pieces of the delivery system – referring physicians, consultants, pharmacies, outside laboratories, outside x-ray and imaging centers, etc. Thus, the future of EHRs for these kinds of settings really does focus on connectivity.

The hospital environment is quite different from this. Hospitals tend to be more self-contained as far as the services provided, and the workflows involved are about communication between different hospital departments – but they are all under the same roof (generally). What an EHR needs to do in a hospital setting is, understandably, quite different from what an ambulatory EHR needs to do.

There is some overlap in Certification criteria (Stage 1) for hospital and ambulatory EHRs, as well as several key differences. As we move forward, these differences will be more pronounced. Adding to this, a lot of money is at stake. Experience to date in Meaningful Use distributions by CMS show that 79% of the total dollars has gone to hospitals, with 21% going to ambulatory “eligible providers.” The average disbursement to hospitals so far has been about $1,150,354 per hospital.

Hospitals undergo periodic accreditation by the Joint Commission (JACHO). In a recent commentary that appeared in JAMA, the recommendation was made to modify hospital EHR systems in order to address the Joint Commission’s National Patient Safety Goals (NPSG) – in essence stating that EHRs need re-designing to meet Quality Improvement mandates. The NPSG goals that are recommended to be built into EHRs going forward are: (1) improving patient identification, (2) improve staff communication between departments or during patient-responsibility hand-offs, (3) improve the safe use of medications, (4) improve infection prevention by having specific checklists, (5) improve medication reconciliation between transitions of care, and (6) assess suicide risk, also by implementing checklists. The Joint Commission has been particularly concerned about “deadly” miscommunications during patient-care hand-offs, and building EHR systems that address these risks is a high priority item.

This makes a lot of sense, as EHRs evolve. It also means that hospital-oriented EHRs are quite different things than ambulatory EHRs – they are tools to facilitate different kinds of work, and respond to different kinds of regulatory environments, including differing sets of patient-care risks.

One of the trends in U.S. healthcare recently has been the re-emergence of hospitals actively acquiring community ambulatory practices – either by direct purchase and hiring of physicians (where state law allows), or by creating structures (the Foundation model) that accomplish the same thing. Resulting from overwhelm and very difficult margins, independent physicians have been selling their practices to hospitals in many geographies around the country.

Often, when this happens, the hospital will provide their hospital-based EHR to the ambulatory practices they have acquired, not realizing how different these settings actually are. As things move forward, and hospital EHRs move in the direction of addressing JACHO-identified risks in the hospital setting (which are issues internal to the self-contained hospital environment), their divergence increases from what ambulatory systems need to become. Ambulatory systems need to be able to create data that is portable, and connectivity with many outside systems (including patient-facing systems) will be the core.

Connectivity between ambulatory EHR systems (especially web-based systems, which imply that the data stores are not housed locally in a doctor’s office) and hospital systems (which have complex inter-departmental workflow management as their in-house issue) will be key going forward. It is more likely that the needed connectivity will originate from the ambulatory-side than from the hospital-side – after all, ambulatory systems will evolve into high connectivity with each other and with outside systems (labs, pharmacies, imaging centers), whereas hospital systems are more self-contained and involved with internal department synergy. As the divergence widens, it becomes increasingly important not to confuse the two. It will be very interesting to see how this all evolves.