Ambulatory EHR vs. hospital inpatient EHR solutions

• The hospital EHR environment
• The ambulatory healthcare environment
• Differences in Certification
• Conclusions

With the success of our web-based ambulatory Electronic Health Record (EHR), a question we sometimes get is “why can’t I use this system in my hospital?” What difference is there between an Inpatient EHR and an Ambulatory EHR?

The difference is quite significant, actually. Let’s start by looking a little deeper into hospital IT issues, and the evolution of tools that try to address them.

The hospital EHR environment
Traditionally, from an IT perspective, a hospital is not really a single system – it is a collection of systems in various departments. Over the past few decades, each hospital department purchased and installed software tailored to that specific department’s function – there would be an x-ray/imaging system that managed images and reports; there would be an in-house lab system; there would be an in-house pharmacy system; there would be a medical records system; a billing system, etc. Each department would print out paper, and the results collected in a patient chart. Computer access to these systems (generally done from a ward clerk’s station, or a nursing station) was often via a different interface for each one, and a paper report was often the easiest way to assemble the information.

Many hospitals are still in this stage of IT development, and are challenged to get all the internal departmental systems to talk to each other. Rip-and-replace of traditional department systems is a very disruptive process that many are loathe to undertake.

As EHRs became more sophisticated, they became the hub that tried to link each of the internal departments together. At first, the EHRs were simply ways of capturing medical records documentation – dictated H&Ps, Procedure and Op Notes, and Discharge Summaries. Linkage with the in-house lab, with pharmacy, with imaging, and with computerized order-taking were all added on with increasing EHR sophistication.

The challenge of integration for hospital systems was internal, generally only needing a single connection with a given department. There is only one pharmacy, one lab, one x-ray department, and so forth. The integrations with each of these could be customized, as the particular systems that had been installed in each of these departments might be unique, non-standard, and maybe locally modified.

The hospital’s EHR is, as one would expect, locally-housed. After all, the connections with department systems is internal, and custom, and best handled by a local enterprise-type system. EHR vendors for hospital-side systems (like Epic, Cerner, and the like) focused on this expectation of deployment. Sometimes, in large multi-hospital systems, the cost of local modification can be huge – Kaiser’s implementation of their flavor of the Epic system cost billions, resulting in something unique, and fairly different from the Epic installations in other hospitals.

The ambulatory healthcare environment
Contrast this scenario with the one faced by community physicians. A physician practice has records that are longitudinal (rather than episode-of-care), and are internal to that practice (rather than all consultants writing into the same chart, as is the case in a hospital record). They deal with hundreds of different pharmacies, not just the one hospital pharmacy department. Generally, there is no in-house x-ray or imaging department, so that connection to such data is an external link. Often, more than one lab is used for the practice’s patients, often determined by the patient’s particular health plan coverage and preferences.

Small practices don’t have the resources to house and locally install an EHR system. Hence the popularity of web-based solutions which dramatically reduce the IT burden for practices.

A web-based solution works well in the ambulatory environment. The records are portable, accessible from anywhere (all one needs is an Internet-connected computer). Information moves between staff members more as messages, rather than orders – the “order sheet” that is a standard part of an inpatient chart does not exist in an ambulatory record. Pharmacy orders (prescriptions) are made to any of thousands of different pharmacies, sometimes to mail-away pharmacies.

Unlike in the hospital, where getting a consultation is in-house, and the consultant accesses the same patient’s hospital chart, consultation in an ambulatory setting is a referral to an outside stand-alone practice. Issues of getting the appropriate clinical (and sometimes insurance authorization) information to the consultant, and of getting a response back from the consultant, represent a whole different set of challenges than those in the inpatient setting.

Differences in Certification
In the era of Meaningful Use, the Office of the National Coordinator (ONC) for Health IT recognized the differences in these kinds of EHR settings. For EHR Certification, there are some elements that are common to both ambulatory and inpatient systems – privacy and security standards, keeping problem lists, medication lists, allergy lists, etc., are universal. There is also a set of Certification requirements unique to ambulatory systems, as well as a different set of requirements for inpatient systems.

Inpatient systems need a different set of capabilities for Computerized Physician Order Entry (CPOE). Ambulatory EHRs need to be capable of electronic prescribing to outside pharmacies; inpatient systems do not (after all, medications are in-house and are handled through CPOE rather than eRx). Inpatient systems need to give patients timely and electronic access to their Discharge Summaries; ambulatory systems need broader access to build-as-you-go summaries and summaries for each encounter.

Clinical Quality Measures for inpatient systems measure different things – there are 15 criteria for inpatient systems, which address things like Emergency Department throughput times, acute stroke management, and deep venous thrombosis (DVT) prevention in bed-bound patients. Ambulatory EHRs need to report on 3 core measures (or 3 alternate-core measures), and 3-of-38 “menu” items, which focus more on management of chronic conditions, immunizations and disease-prevention screenings.

Conclusions
An EHR system built to be an ambulatory solution won’t work well for an inpatient setting. Similarly, an inpatient EHR pushed out onto ambulatory practices won’t work well either. The issues, workflows, and certification criteria are different.

The nature of ambulatory care lends itself well to a web-based EHR solution. It is much more difficult to use a web-based solution in an inpatient setting, since connection to hospital department systems is likely to be quite locally-customized. There is a need for low-cost web-based systems for inpatient use, particularly for smaller hospitals with limited IT budgets – a business niche that hopefully will be addressed by the EHR developer community.

Of course, a web-based EHR can be accessed from anywhere, including within the hospital. Thus, the patient’s ambulatory record can be reviewed, and even cut-and-pasted into in-hospital documentation. As the platform of true interoperability (the promise of Health Information Exchange) matures, connectivity between local hospitals (and each of their internal departments) and ambulatory community EHRs may eventually take place. It is still a little ways off, but we are all building towards that future.

Robert Rowley, MD
Chief Medical Officer
Practice Fusion EMR