Margret Amatayakul

If your organization is considering rolling out ambulatory electronic health record (EHR) systems to physicians on your organization's medical staff, you may want to do some homework.

An increasing number of IT vendors are offering hospitals and integrated delivery systems (IDSs) the ability to roll out an ambulatory EHR not only to their owned practices, but also to members of their medical staffs who are in independent practices.

Vendors often refer to these EHR rollouts as "community offerings," "enterprise offerings," "clinical integration solutions," "end-to-end solutions," and more. Although conceivably the rollout of an ambulatory EHR system to a medical practice could be made by a healthcare organization as part of a donation under the EHR/e-prescribing exceptions to the Stark and anti-kickback laws, in general, it appears that the offerings are more commonly provided by hospitals or IDSs to members of their medical staffs for full market value as a way of avoiding the legal issues potentially arising from such laws. Additionally, hospitals and IDSs recognize that the EHR/e-prescribing exceptions will be around for only a few more years (until 2013).

The primary benefit of the donation of an ambulatory EHR system to a medical practice-for both the healthcare organization and physicians-is "interoperability," a word that carries many promises, with varying degrees of actual results.

Virtually all the offerings provide a standard configuration to address not only technical interoperability between the hospital and medical staff offices, but also process interoperability for more seamless workflow. Ideally, such interoperability will lead to better access to health information to improve quality of care, patient safety, and care coordination.

What Types of Ambulatory EHR Systems Are Being Offered?

In actuality, there are probably three "flavors" of ambulatory EHR offerings, with differences in interoperability.

Completely integrated. This offering affords the greatest level of interoperability, with one vendor supplying all applications for the enterprise. In a completely integrated system, all patient records are physically within the same database, separated by logical (access) controls. Not only are the applications seamless, but also access can be afforded to all patient information across the continuum of care (within the IDS).

Strongly interfaced from one vendor. This offering usually is provided by a single vendor, but you must apply caution: The vendor's ambulatory product may not have been built from the same platform; hence, the application has been given the same "look and feel" and has been well-interfaced. When used within an IDS, some applications between the hospital and physician office may not be accessible, and others may require separate log-ins or noticeable variations in how they work.

Different vendor offerings that contribute to a central repository, which may be transactional, analytical, or both. In this instance, an IDS has settled on one or two different products to endorse, configure, and roll out to physicians-supporting the necessary interfaces to the hospital's lab, provider portal, computerized provider order entry system, and potentially other components of the EHR-and in some cases aggregation of data for quality improvement.

Important Considerations

Although any of these ambulatory EHR models may sound like a win-win situation for all-hospitals, physician offices, and patients-some of the offerings are going over very well, and others are not. Hospitals should consider the following questions in selecting an ambulatory EHR system for rollout.

Is the ambulatory product being offered suitable for the size of your medical staff offices and the types of physicians on staff? This is of special concern where the ambulatory product being offered is primarily suitable for small offices and may not scale well to larger practices. Closely related is the degree of customization the healthcare organization is able and willing to provide. This concern is particularly important for specialists and for clinics that operate as federally qualified health centers, community health centers, or other special facilities that may have different reporting and reimbursement needs.

Does the ambulatory product being offered have all the features and functions that physician offices could get from other products-potentially even at less cost?  Some of the ambulatory care products offered by hospital information system vendors are ideal, where others may not have all the features desired by physicians for their offices. If the vendor acquired the product from another vendor, it may not be kept up-to-date with newer features. In some cases, the availability of desirable features is a function of the product, and in some cases, it is a function of how the hospital will configure and roll out the product. In addition, when overhead of the hospital is factored into some of these offerings, the "deal" may not be as desirable.

Also related to this issue is whether the offering includes a practice management system, which the physician office may or may not want to adopt in place of its existing practice management system, and whether the offering organization will undertake interfaces to existing systems if physicians do not want to change. This question adds another major layer of cost and complexity to the offering.

How "close" do independent practices want to get with their hospital? Some practices, especially in metropolitan areas, may admit patients to more than one hospital. If hospital A is the offering hospital, the practice also will have some of hospital B's patients in its database, and the physicians may be sensitive to this issue. An associated issue is ensuring that physician billing records are separate-another important area of sensitivity for physicians.

Are there patient consent issues that should be addressed in a shared offering? In a true health information exchange organization, this issue is usually addressed explicitly. Within the IDS, patient consent may not seem to be an issue, but there are very likely to be concerns from patients. Preserving confidentiality and ensuring patients' consent directives can be managed is critical.

As IDSs consider these offerings, it is appropriate to evaluate the motivation behind them and engage physicians early in  the thinking and planning stages.

Margret Amatayakul, RHIA, FHIMSS, is president, Margret\A Consulting, LLC, Schaumburg, Ill. (

Publication Date: Tuesday, September 01, 2009

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