EHR Implementation in Ambulatory Care A White Paper by the HIMSS Ambulatory Paperless Clinics Work Group Copyright 2007 by the Healthcare Information and Management Systems Society HIMSS Introduction The President s Executive Order issued in April 2004 calls for widespread use of electronic health records for all Americans by 2014 Yet adoption rates for this technology remain surprisingly low The CDC s National Center for Health Statistics announced in the summer of 2006 that while nearly one quarter of the nation s physicians 23 9 percent reported using full or partial electronic health records EHRs in their office based practice just one in ten physicians 9 3 percent used EHRs with the four basic functions e prescribing computerized provider order entry automated reporting of test results and physician documentation considered necessary for a complete EHR system 1 Many researchers and groups including the HIMSS Global Task Force have examined existing barriers that hinder EHR adoption In the United State and in other countries four common barriers have been identified communication standardization funding and interoperability 2 This report offers differing experiences and perspectives of ambulatory care practices that have adopted or attempted to adopt health information technology into their daily medical practice While some practices have clearly struggled to become paperless others have enjoyed great success It is from their stories and case studies that we can contribute to a larger body of knowledge that will ultimately help more medical practices successful adopt EHRs The different aspects of EHR implementation addressed in this paper include what to do with the paper record choosing appropriate technology project management configuration needs training needs the case for quality and return on investment What to Do with the Patient Record Planning for a new electronic patient record generally begins with a discussion about what to do with the old paper record This is a complicated decision based on numerous factors What follows is one clinic s innovative method for moving data from the paper record into an electronic one Generally speaking this is done via a mix of scanning and abstracting One of the obvious benefits of implementing an EHR is the elimination of the paperbased patient charts and all of the costs and inefficiencies associated with them When Roswell Pediatric Center in Alpharetta Georgia implemented the Noteworthy Medical Systems EHR in 2001 they worked with the implementation team to plan and execute a coordinated transition from paper based to electronic charts for each of their 38 000 patients Once the transition was complete Roswell was able to ship all paper based charts off site Roswell now uses the EHR for each of their 90 000 patient visits annually Roswell s transition was carefully planned and coordinated The first step was determining which information to enter by hand and which could be simply scanned into the EHR To make this decision the implementation team identified the information 2 necessary for the EHR to provide clinical decision support A Critical Data Checklist CDC was created that listed the items to be hand entered Immunization history allergies current medications and growth histories among other items made the checklist It was important that these items be hand entered into the Noteworthy EHR and stored in structured database format so that Roswell could take full advantage of well care reminders immunization forms and growth graphs that had been set up in the system To enter the designated information into the electronic chart Roswell brought in six parttime employees to help While most of these employees had no clinical training they did have prior experience on Roswell s front desk and were therefore familiar with their paper based patient charts Each day they would enter the information for patients with checkups the following day according to the Critical Data Checklist When the patient arrived for their checkup Roswell staff would route the paper based chart to the practitioner for comparison with the newly created electronic chart When inconsistencies were found the practitioner corrected them during the encounter so the paper based chart could be retired Once the practitioner was convinced that all pertinent information had been hand entered he or she signed the Critical Data Checklist and from that point on only the electronic chart was used for that patient In total the process of pulling paper based charts prior to patient check ups and use of the Critical Data Checklist lasted several months Ultimately Roswell s approach began to pay dividends as patients returned for additional well child checkups and the patients electronic chart was complete After six months the six part time employees were no longer needed and the front desk personnel had enough time to enter patient history according to the CDC as sick child visits were scheduled In an effort to remain paperless Roswell began scanning incoming clinical documents shortly after go live Many of the 1 500 paper documents received each day are now scanned into the patient s electronic chart after being reviewed and signed by a practitioner Roswell also scans much of its administrative documentation into the EHR as well making the practice completely paperless Appropriate Technology Other critical decisions made early in the life of the project concern the type of technology that will support the EHR Most clinics will require the help and expertise of an information technology professional to ensure that the office network is of sufficient quality to support the EHR and to establish safe and secure practices for maintaining highly confidential patient data 3 Cockerell and McIntosh Pediatrics is a two office pediatric clinic in the Kansas City metro area The practice is made up of seven physicians and three nurse practitioners providing pediatric and adolescent care to over 25 000 patients Cockerell and McIntosh Pediatrics provides on site laboratory and radiology services allergy and asthma care and an urgent care clinic during evening and weekend hours In 2003 Charles F Cockerell MD began researching EHRs and decided to purchase Misys EMR The following text outlines some of the hardware considerations that are associated with the implementation of an electronic medical record EMR Infrastructure Cockerell and McIntosh Pediatrics houses seven servers at its primary