Development of Ambulatory Electronic Medical Records

A Clinical Information System (CIS) is a computer-based system that collects, stores, and makes critical clinical information accessible to the healthcare delivery process. CIS can be used as a network with many computer systems in a clinic. Clinical Information System involves the entire organization, as it is a foundation that allows the organization to work properly. The Clinical Information System provides a data storehouse that stores data like the patients’ healthcare history and interactions with their health care providers. This storehouse source encodes information that can help physicians make good health decisions about patients’ healthcare conditions, treatment options, and wellness activities and other relevant information that aid in improving the health care of the patients (“Clinical Information Systems (CIS) 101 | BioHealthMatics.com,” 2018).

A CIS can benefit both patients and clinicians by improving communication between both parties; by providing all the relevant information clinicians need to make good healthcare decisions for patients; by encouraging increased patients’ quality improvements and by allowing better clinical research. CIS can be used in emergent situations to gain immediate access to a patient’s complete medical history. Physicians can use CIS to send medical prescriptions directly to pharmacies, where they can be easily picked up as patients leave the clinic. One advantage of CIS is that they can interrelate with other subsystems in a hospital, e.g., the pharmacy, different laboratories, and image processing systems (Islam, Poly & Li, 2018). A good CIS contributes to patient’s safety, workflow efficiency, and clinical decision support (Moen & Maeland, 2013). 

Ambulatory EHRs

Clinical Information Systems are those information technology systems used by clinical staff and health care providers to provide care to patients and are utilized near the point of clinical care. Some examples of CIS are Ambulatory or Outpatient Clinical Information Systems including the Ambulatory/OPD (Out Patient Department), Electronic Medical Record (EMR). These systems can be used in outpatient physicians’ clinics like the clinical offices of rheumatologists, nephrologists, and primary care physicians.  Ambulatory/OPD information systems should consist of two well-integrated components. The first component is the clinic administration and management system and includes the registration function, and the scheduling and billing functionalities also known as the Practice Management system (PM) (“Clinical Information Systems An Overview: Dr Pramod D. Jacob Consultant Clinical Information Systems/EMR,” 2019). The second part is the actual ambulatory healthcare delivery system and that is the Ambulatory EMR.

Goals of the Ambulatory EMR.

Ambulatory clinical information systems are utilized and beneficial for the outpatient clinic visit between a patient and his or her physician caregiver. An example of a workflow scenario is: a registered patient presents for a scheduled doctor’s visit and is checked in at the front desk. The patient is held in the waiting room and called into the examination room by the appropriate clinical staff where the patient’s chief complaint, vitals, and nursing notes are documented via the EMR (Electronic Medical Record). The doctor comes in, reviews the case, conducts his or her own physical examination, and make relevant medical orders (e.g., laboratory test orders and medication prescriptions). The patient then proceeds to the laboratory clinics for ordered blood or urine tests. The patient goes to the pharmacy to collect his/her prescribed medications and then completes the scheduled doctor’s visit by checking out after paying their accumulated bill. Outpatient clinics uses ambulatory EMR systems to replace paper lab forms and paper prescriptions. Ordering of certain clinical tests and medications can be accomplished electronically via the EMR. Ambulatory EMR has chart and result’s review features that allows for the review of patient clinical visits, results of lab tests and relevant clinical information like the patient current medications. Clinical documentation like progress notes, medication administration records and nursing notes can be documented and stored in the EMR system. Laboratory orders, medication orders and doctor referrals can be done electronically on the computer system.

The EMR can be interfaced with the clinic’s Pharmacy Information System for handling medication orders and the Lab Information System for lab orders going through and the results to be transmitted (“Clinical Information Systems An Overview: Dr Pramod D. Jacob Consultant Clinical Information Systems/EMR,” 2019). An emailing system can be created and implemented to communicate about abnormal test results and communicate with other members of the provider health care team. This event is another way to coordinate and follow up on a patients’ health care needs. The EMR should be well integrated with the Practice Management system to stimulate back-end processes, like the generating of a charge for a clinic visit in the billing system, after the doctor closes an encounter in the EMR (“Clinical Information Systems An Overview: Dr Pramod D. Jacob Consultant Clinical Information Systems/EMR,” 2019).

eClinicalWorks

eClinicalWorks is an example of an ambulatory outpatient clinical information system that can be implemented and useful in various outpatient clinics like the clinic of a rheumatologist. eClinicalWorks is a Massachusetts-based company that sells electronic medical record (EMR), practice management and personal health record software and services to healthcare providers. According to the company, more than 115,000 physicians and 70,000 facilities in the United States use its software (“ECW Implementation Guide,” n.d.). The company’s unified Electronic Medical Records (EMR) and Practice Management (PM) system coordinates patient office visit flow from the beginning of the visit to the end and streamlines processes regardless of practice size, specialty, and number of locations (“ECW Implementation Guide,” n.d.). eClinicalWorks has a patient portal feature that allows patients and care givers to communicate easily, safely and securely over the Internet. eClinicalWorks Electronic Health eXchange (eEHX) is the main reason behind clinical integration systems becoming community-wide projects (“ECW Implementation Guide,” n.d.). The CIS allows only qualified caregivers access to medical records and is much more secure than a paper chart.

Goals of eClinicalWorks

The Clinical related goals of eClinicalWorks includes the provision of efficient clinical documentation; improvement of patient communication and education; and improvement of patient engagement (Mehta, 2016). The Operational goals of eClinicalWorks include the improvement of patient flow; intergration of care via devices and improvement of patient flow and satisfaction (Mehta, 2016). The Implementation goals are to create strong communication nodes; achieving project milestones and meeting projected deadlines (Mehta, 2016). The Support goals of the eClinicalWorks CIS includes creating super users and clinical champions and the support of training process (Mehta, 2016).

Roles of implementation/installation of eClinicalWorks in an outpatient clinic

There are various roles delegated for the installation and implementation of this Clinical Information System. For small clinics, like for a primary care provider, a person can be assigned to multiple roles. Role titles include a Project Lead, an Integration Project Manager, a Business Analyst, a Clinical Champion, a Steering Committee, a Workflow Coordinator, eClinicalWorks Specialist, and a Practice IT. The Steering Committee consists of the decision makers of every aspect of the implementation process (Mehta, 2016). The Project Lead is responsible for leading the practice on EMR adoption and for the overall success of the EMR adoption and rollout (“ECW Implementation Guide,” n.d.). The Project Lead also communicate and collaborate with eClinicalWorks PM/IM to meet scheduled timelines, milestones and deliverables and mitigate internal and external risks (“ECW Implementation Guide,” n.d.). The Clinical Champion Lead owns, manages and customizes database content based on the clinical practice workflow (“ECW Implementation Guide,” n.d.). Clinical champions are made of Super users from various departments of the clinic who are experts or well-versed on the implementation of the CIS and can aid others in the training process (Mehta, 2016). The Workflow Coordinator is responsible for managing and documenting the day to day schedules and organizing meetings for the EHR process (“ECW Implementation Guide,” n.d.). The Workflow Coordinator completes workflow documentation and follow-ups on enquiries between meetings (“ECW Implementation Guide,” n.d.). The Practice IT Manager assist eClinicalWorks with the install-related tasks and supports the IT infrastructure of the clinic (Mehta, 2016). The Business Analyst is responsible for workflow and analysis (Mehta, 2016). The Integration Project Manager (IPM) oversees interface project plans to improve and support the business activities (Mehta, 2016). The eClinicalWorks Specialist (EIS) is the system product expert that is available to offer any assistance during the pre and post-implementation process of the system (Mehta, 2016).

The Approach Stages of Implementation

Initiation

The Implementation timeline is a guideline, for a typical implementation and is dependent on the size and scope of the clinic. Typically, the Go-Live date is scheduled between 12-16 weeks after the Kick-off Call (“ECW Implementation Guide,” n.d.). The Project Kick-Off stage is the stage where the project objections are defined. This is the data collective stage. The data gathering includes activities like billing discovery, clearing out enrollment and data migration scoping (Mehta, 2016). A Kick-off is performed by the Project manager.  He/she helps make the choices with integration features and provides milestone dates as part of the Implementation timeline (“ECW Implementation Guide,” n.d.). The next initiation step is to establish the Billing Discovery Call. During this call, the billing manager answers a series of questions to inform eClinicalWorks (eCW) about the clinic’s billing processes (“ECW Implementation Guide,” n.d.).

 The next steps in the initiation process are the Clearinghouse Enrollment, Data Migration and Lab Interface steps (“ECW Implementation Guide,” n.d.). The Clearinghouse Enrollment, Data migration and Lab interface processes are continuous throughout the implementation of the CIS. Clearinghouses saves time and money by accelerating the process of claim submission. One can submit claims electronically to the Clearinghouse, and the Clearinghouse submits the claims electronically to the insurance companies of interest (“ECW Implementation Guide,” n.d.). The most common Clearinghouses currently used by eClinicalWorks customers are Emdeon and Gateway EDI (“ECW Implementation Guide,” n.d.). eClinicalWorks offers a Data migration service as a vital part of the implementation process. This entails retrieving data from existing practice management system and transferring it to eClinicalWorks in two separate increments (“ECW Implementation Guide,” n.d.). eClinicalWorks can retrieve and migrate existing data, like patient demographics, physicians’ appointments information and insurances information (“ECW Implementation Guide,” n.d.). The two options eClinicalWorks offers for gathering data for migration includes having eClinicalWorks extract from their current practice management system and having the client provide the data. Quest or Labcorp laboratories use eClinicalWorks integration to transmit laboratory data electronically. The lab interfaces may be Uni-directional or Bi-directional. eClinicalWorks’ Lab programmer can assist in the process of sending a Lab Compendium Spreadsheet that is filled out by the clinic and transferred to the lab of interest using eCW (“ECW Implementation Guide,” n.d.).

Optional Integration Features

eClinicalWorks has developed an interface with Midmark EKG, Spirometer, Vitals and Holter devices (“ECW Implementation Guide,” n.d.). eClinicalWorks also integrates with several Welch Allyn Spot Vital Signs, devices, Spirometers, Ambulatory Blood Pressure devices, EKG, and Stress Test machines (“ECW Implementation Guide,” n.d.). eClinicalWorks support Patient Portal systems that enables the sharing of information and communication with clinicians and patients. Medical record information including laboratory test results, diagnostic imaging tests, and medical alerts are conveyed on the patient portal. An influence in population health is the eEHX which is an electronic health exchange – platform to exchange and manage data from varying sources.

eClinicalMessenger is a new voice messaging service that can be used to improve communication skills between the doctor and the patient. eClinicalMessenger utilizes Voice-over-Internet Protocol (VoIP), enabling the clinic to send voice messages to its patients (“ECW Implementation Guide,” n.d.). This is an effective take on phone messaging service, as it is integrated into the eClinicalWorks® solution. Benefits of eClinicalMessenger includes integration with the EMR product version 8.0; and Bi-Directional capabilities to allow patients to confirm appointments over the phone and automatically updates in the EMR (“ECW Implementation Guide,” n.d.).

Planning

The planning stage of the implementation consist of the Business Analysis site visit, and Hardware installation (Mehta, 2016).  The Hardware Approval involves the provision of hardware specifications to eClinicalWorks for review and approval (“ECW Implementation Guide,” n.d.). Proper hardware and network configuration are essential to the success of the eClinicalWorks system implementation. eClinicalWorks provides a Hardware Requirements document that states the minimum requirements needed for the network. The clinic reviews this document with their IT specialist to ensure proper ordering or upgrading of equipment in the future. The Install Check is performed by eClinicalWorks, weeks before onsite training, to ensure the network meets specifications and all hardware and devices are ready for Installation (“ECW Implementation Guide,” n.d.). eClinicalWorks remotely connects to the client’s network via a remote desktop sharing program or a Remote Desktop Connection (RDC) (“ECW Implementation Guide,” n.d.).The Install check verifies that all network components, machines, and software are configured correctly and working correctly; verifies that systems are functioning according to eClinicalWorks hardware specifications; verifies that all the service packs are installed and can test the scanner used (“ECW Implementation Guide,” n.d.). The installation of eClinicalWorks is performed 3 – 4 weeks before onsite training (“ECW Implementation Guide,” n.d.). The eClinicalWorks Installation team remotely connect to the client’s Network and install the software on the server (“ECW Implementation Guide,” n.d.). A business analyst is involved in the design or modification of IT systems and interacts with the clinic and subject matter experts to understand problems and needs that might arise in the implementation process. The analyst gathers, documents, and analyzes the CIS needs and requirements.

Execution and Evaluation

The execution stage is the final stage of the implementation process. It consists of the Software deployment, Interface install and testing, System build, the Training and Go-live phases (Mehta, 2016).   The eClinicalWorks Training Program is created to convey effective working knowledge of all eCW functionality that applies to the practice’s needs and facilitate the integration of the eCW EMR/PM system (“ECW Implementation Guide,” n.d.). It makes available opportunities to work hands-on with the program, and allows participants, like the clinic staff, the opportunities to test with what they have learnt in stimulated work-related scenarios. Prior to onsite training, eClinicalWorks can provide an online EMR System Build session (“ECW Implementation Guide,” n.d.). The purpose of this is to help prepare for the onsite training by revealing the ways in which the clinic staff can get started with EMR customizations (“ECW Implementation Guide,” n.d.). EMR System Build is intended for the clinical lead of the practice and/or those involved in the customization process of the EMR system. Super users (technically-proficient staff members) support the less knowledgeable staff members on the EHR system during the training process, the Go Live period and yonder. It is imperative and beneficial to identify super users, train them on the eCW system early, and involve them in the workflow redesign and EHR configuration (“ECW Implementation Guide,” n.d.).

Accurate system configuration will assist the clinic staff in successfully following appropriate practice policies and procedures and ensures that the clinic can collect and monitor the information it needs to conduct proper business (“ECW Implementation Guide,” n.d.). The clinical practice is responsible for entering required information (such as provider schedules), reviewing the CIS to ensure that the appropriate fields and reports are available/accessible, and configuring custom fields (“ECW Implementation Guide,” n.d.). The eCW Implementation Manager assist the super users in identifying areas of the system that need configuration and provide configuration options, based on best practices from other implementations. System testing is the concluding chance to review the restructured workflows and configuration. The testing period ensures revised practice workflows can be successfully altered to site-specific staffing and procedures. The super users and project lead should also spend ample time at each go-live site to test the workflows, ensure the appropriate settings are available to the staff who will be using them, and check to make sure hardware is properly installed and functioning well (“ECW Implementation Guide,” n.d.). Successful testing includes: submission and receipt of payment of claims to each of the practice’s primary payers; order, collection, processing and receipt of lab results from the practice’s primary lab; and audit of all users that are entered into the system (to ensure all users have eCW accounts and all providers have eCW licenses) and a list of security permissions set by role (“ECW Implementation Guide,” n.d.). The SAM (Strategic Account Manager) is assigned to the clinic practice for up to 16 weeks to aid when the clinic goes live on the eClinicalWorks system (“ECW Implementation Guide,” n.d.). The SAM conducts a Support Kick-Off Call when the training period is completed. The SAM also conducts three evaluations throughout the 16-week go-live period to ensure the EMR and PM adoption at the clinic (“ECW Implementation Guide,” n.d.).

Conclusion

Clinical information systems and computerized clinical decision support have made numerous contributions to medicine and by using better medical knowledge, optimized clinical information systems, and computerized clinical decision, we will enable improvements in both the quality and safety of patient care in the next twenty-five years (Gardner, 2016). The use of clinical information systems has created opportunities for meaningful improvements in patient care, however, healthcare providers are still facing challenges of data exchange, management, and integration due to lack of functionality among these systems (Islam, Poly & Li, 2018). Clinical information systems provide great opportunities to eliminate clinical errors such as medication errors and supports healthcare professionals by offering up-to-date patient information. They help improve workflow and efficiency of care and help boost the overall quality of healthcare.

References

• Moen A, Maeland Knudsen L M. (2013). Nursing informatics: decades of contribution to health informatics. Healthc Inform Res.19(02):86–92.
• Islam, M. M., Poly, T. N., & Li, Y. J. (2018). Recent Advancement of Clinical Information Systems: Opportunities and Challenges. Yearbook of medical informatics, 27(1), 83–90. doi:10.1055/s-0038-1667075
• Gardner R. M. (2016). Clinical Information Systems – From Yesterday to Tomorrow. Yearbook of medical informatics, Suppl 1(Suppl 1), S62–S75. doi:10.15265/IYS-2016-s010
• Clinical Information Systems (CIS) 101 | BioHealthMatics.com. (2018). Retrieved from http://www.biohealthmatics.com/technologies/hospital-information-systems/clinical-information-systems/
• Clinical Information Systems An Overview : Dr Pramod D. Jacob Consultant Clinical Information Systems/EMR. (2019). Retrieved from https://ehealth.eletsonline.com/2008/07/clinical-information-systems-an-overview-dr-pramod-d-jacob-consultant-clinical-information-systems-emr/
• ECW Implementation Guide. (n.d.). Retrieved from https://www.scribd.com/doc/45753346/ECW-Implementation-Guide Mehta, N (2016). eClinicalWorks Implementation. Retrieved from https://prezi.com/s9i2bztidkmy/ecw-implementation-process/