Electronic health record systems are the backbone of ambulatory practices today and need to be designed and tailored to meet the specific needs of physicians. Ambulatory EHRs are tasked with streamlining workflows, improving care and helping to trim costs. And like every technology, ambulatory EHRs are evolving, changing in different ways to meet the constantly transforming healthcare marketplace.

It’s up to physician group practices, health systems that own numerous group practices, and other ambulatory healthcare organizations to stay abreast of change to make sure they are getting the most out of their EHRs, and to make sure that they don’t fall behind technologically in a highly competitive industry.

Ambulatory EHR experts at both provider and vendor organizations have a wide variety of informed opinions and helpful insights as to where the technology is headed next so that ambulatory healthcare provider organizations can best prepare for where they need to be in the years ahead. And they share their expertise here, as well as in a checklist of both evolutionary changes coming soon and ways organizations can future-proof in advance of such changes and in a case study of an ambulatory EHR in action.

Connectivity backbone

But to understand where ambulatory EHRs are headed, it’s important to first understand where things stand today. EHR experts have lists of components that they believe make up a high-quality ambulatory EHR now.

Among ambulatory provider organizations in the top 5 percent that have attested for meaningful use, Epic, Allscripts and athenahealth are the top EHRs for solo practitioners and for group practices with 2 to 25 physicians, according to research from HIMSS Analytics. Epic, Allscripts and Cerner come out on top for group practices with 26 or more physicians.

[Case study: How one medical group uses its EHR to tackle three big goals and here's a checklist:10 steps for future-proofing your ambulatory EHR investment] 

An ambulatory EHR should have the power to connect communities, providing clinicians immediate analysis and insights to initiate meaningful change, said Allscripts CEO Paul Black.

“Think of it as a practice’s backbone technology that significantly and positively impacts patient care delivery and outcomes,” Black said. “To achieve these results, it is critical for the EHR to have the capability to customize workflows, and coordinate and deliver primary and specialized care.”

Clinicians want to take great care of patients while staying independent and financially viable. They do not need complicated systems that create as many headaches as they solve.

“Clinical and financial functionality is important,” Black said. “Fundamental components such as e-prescribing, mobile access and robust, flexible clinical features will help practices deliver quality patient care, combined with powerful financial and administrative support.”

Optimizing decision-making

A comprehensive chart is critical to an ambulatory EHR, one that provides enough information to optimize clinical decision making and care planning and prevents the need to repeat tests or the risk of potentially doing harm, for example, administering a medication for which the patient has a severe allergy.

“EHRs need to employ effective clinical documentation tools that allow clinicians to capture patients’ current condition/disease states, both delivered and planned care, and satisfy regulatory requirements seamlessly,” said athenahealth Director of Ambulatory Services Jasmine Gee. “This frees up clinicians to do less administrative work and spend quality time with more patients.”

Another must-have for ambulatory EHRs is computerized physician order entry – effective CPOE tools enable easy order entry (for instance, labs, imaging, referrals, etc.) and present information to physicians that drives more effective ordering decisions, Gee added.

“And EHRs must be offering, embracing and actively improving interoperability,” she said. “The ability for the clinician to construct a 360-degree view of a patient’s clinical information, regardless of where care has been delivered, is only possible if the EHR proactively searches for and consolidates information across both traditional and non-traditional data repositories.”

"Today’s EHR must offer doctors methods to connect with patients outside of the walls of the office to help them stay healthy."

Girish Navani, eClinicalWorks

And fundamental to any ambulatory EHR are tools that help providers better understand each patient’s needs, more accurately gauge risk, and promote more effective treatment and improved outcomes, said Girish Navani, CEO and co-founder of eClinicalWorks.

“Specifically, tools for interoperability to improve outcomes and the transmission of data, population health to analyze critical health information, and patient engagement services to virtually connect the patient and providers,” Navani said. “These tools are crucial to establishing expanded intelligence and creating inferences that improve care outcomes.”

State of the art

Ambulatory EHRs today are marked by a variety of top features and functions, the state of the art from which the technology will grow into the future.

“Capabilities enabled by technology are emerging with most EHRs able to provide some level of access to patients and providers to participate and collaborate during the care cycle,” said Robert Van Tuyl, CIO of Easter Seals of the Bay Area, which uses athenahealth’s ambulatory EHR. “Patient portals for access to at least a subset of their electronic medical record, scheduling appointments, and participation at a beginning level of remote care, is possible today.”

On another note, standards like FHIR are emerging for the exchange of electronic medical records between providers, but a lack of adoption and/or willingness to share this data efficiently and effectively with outpatient healthcare providers still is creating challenges to implementing fully integrated care.

Elsewhere, today’s EHRs should offer not just methods and tools to make a doctor’s office more efficient, but ways for doctors to connect with patients more meaningfully, said Navani of eClinicalWorks.

“Providers are moving from the traditional fee-for-service to more of a value-based care, forcing EHRs to cater to the evolving needs and changes with modules to better manage quality programs,” he said. “Today’s EHR must offer doctors methods to connect with patients outside of the walls of the office to help them stay healthy. The connection will allow providers to be successful at the different quality programs they participate in, such as reminder services, portals, and other patient engagement tools that are directly integrated into the EHR.”

How doctor’s work

Today’s ambulatory EHRs should work the way physicians work, said Richard Atkin, CEO of health IT vendor Greenway Health. If EHRs give physicians time back and improve their quality of life, they can focus on providing the best quality care to patients; EHRs today should provide added value to ambulatory practices and serve as a one-stop-shop system, Atkin added.

“The collective data recorded in the EHR should be in a discrete format and suggest preventative steps that can be taken – additional office visits, exams, tests – to give the patient the best chance of achieving the highest quality of care,” he said. “While business intelligence and automation features like this are common in other industries, they’re only now becoming mainstream in healthcare.”

In addition, EHRs that support patient portals and messaging systems are a must-have today in the age of healthcare consumerism, he added.

Allscripts CEO Paul Black said the state of the art in ambulatory EHRs today includes four components: mobility, the cloud, comprehensiveness and data sharing.

“Mobility gives you what you need, when and where you need it,” he said. “The cloud reduces total cost of ownership while improving scalability and security. A comprehensive solution integrates practice management and patient engagement. And data sharing delivers a single, shared patient record.”

The future of ambulatory EHRs

So where are ambulatory EHRs evolving toward? What will be the features and functions of tomorrow that group practice physicians can’t live without? Ambulatory EHR experts point in many directions, from artificial intelligence to genomics and more.

“Ambulatory service providers are in the unique position to provide comprehensive integrated care management and care coordination across a spectrum of services,” said Van Tuyl of Easter Seals of the Bay Area. “The ability for cloud-based ambulatory EHRs to ingest data from multiple data sources including medical devices and consumer health activity devices and provide a longitudinal view of services provided and care-team interactions will be key to integrating more advanced technologies like artificial intelligence and machine learning to reach better outcomes and efficiencies across the healthcare system.”

Patient engagement through mobile apps for managing health and wellness could be the driving force to making personal medical records a reality with which EHRs will need to exchange data, he added. Consumer-facing apps like Apple Health Records could provide availability of near-real-time data from a variety of trusted devices to augment and enrich medical records that reside within traditional electronic medical records, he said.

"It is critical for the EHR to have the capability to customize workflows, and coordinate and deliver primary and specialized care."

Allscripts CEO Paul Black

In the future, EHRs will not just track a patient’s adherence to his or her care plan but also alert providers when a patient is missing certain elements or when specific steps of the plan have not been completed, said Atkin of Greenway Health. Machine learning will be more commonplace in EHRs, guiding the provider and suggesting medications or care plans based on additional patient data and information stored in the system, he added.

“Genomics will also unlock new possibilities for personalization and wellness in healthcare, allowing provider organizations to design transformational experiences for patients,” Atkin said. “Additionally, behavioral health and socioeconomic factors will become important elements. For example, a patient may not be coming to doctor appointments as recommended because he or she lives in an underprivileged area without transportation. This ultimately tells providers that overall community changes need to be made in order for patient outcomes to improve.”

Offering different choices

Looking ahead, EHRs will also be capable of evaluating the financial implications of clinical decisions and giving a set of different choices – such as various treatment options and drug prices – to improve the patient experience, meet their rising expectations and reduce costs even more, Atkin said.

And next-generation EHRs should be more advanced in the way they receive information, leveraging voice recognition to cut down the administrative process of entering data even more, he added. This will have even bigger benefits as providers work to spend more time with patients and less on documentation, he said.

Artificial intelligence will be a critical element in the evolution of ambulatory EHRs. Incorporating machine learning capabilities to learn physician treatment patterns, for example.

“It can pre-populate information based on these patterns and deliver preference reminders,” said Allscripts’ Black. “It’s constantly surveilling trends by user, organization and region to create opportunities for more efficiency. Plus, the power of artificial intelligence surfaces information relevant to the encounter in real time, which helps improve quality and immediate interaction with the patient.”

Ultimately, this reduces the amount of time spent on documentation, helping address the problems of EHR fatigue and physician burnout, he added.

In addition, more and more vendors will have open IT systems. Open architecture makes it easy to create apps, share data and upgrade individual components of a platform.

“When we add true vendor-agnostic interoperability, we enable providers to seamlessly communicate and exchange data with any trusted system and use that data to make better informed decisions at the point of care and beyond,” Black said.

On the horizon, EHR makers will incorporate EHR-agnostic precision medicine and genomic capabilities within their workflow, Black said.

“These types of capabilities,” he added, “should capture and store genomic data from a range of sources, harmonize clinical knowledge and genomic research to identify relevant information, and then push the resulting insights to the point of care to better determine the most effective regimen for the patient.”

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com