The use of electronic medical records (EMRs) in small and midsize ambulatory practices can result in many of the same benefits as in large practices, including migration from paper charts, electronic ordering, charge capture, and improvements to patient safety and quality of care as a result of features such as clinical decision support. According to Judy Hanover, research manager with IDC, however, small practices do not see the economies of scale that accrue with process efficiencies upon EMR introduction in larger practices, making the ROI questionable for many small practices. "For small practices, selecting the right EMR and choosing functionality that meets the practice’s needs, without creating unnecessary complexity or support costs, are critical," she says.

With stimulus funding in the mix, the outlook for ambulatory EMR adoption had never looked brighter than it did in 2009, Hanover contends. Although adoption of EMR among all practices is currently estimated to be below 10 percent, various industry estimates predict that 50 percent to 60 percent of all U.S. providers will take advantage of stimulus funding to install EMRs by 2016.

Historically, goals for early-adopter practices implementing EMRs have centered around changing their practices and providing better, safer, and more-efficient care, specifically including return on investment, improved documentation, going paperless, lowering costs, and creating improvements to the quality of care and preventing medical errors.

"Going forward, providers will implement ambulatory EMRs with the goal of not only changing their practices, but also receiving stimulus payments," Hanover says. "Meeting federally defined meaningful-use criteria is a primary objective for providers that will rely on the stimulus payment to make their EMR investment financially feasible.

"The expectation is that vendors going forward will focus on providing functionality to meet the meaningful-use criteria, or that in addition to acquiring EMRs, physician practices will also have to invest in other technologies (specifically health-information exchanges, or HIE) to meet the objectives set forth in the final rule."

Smaller practices may be strained to make these additional investments, she adds, and may incur costs far beyond the level of the stimulus subsidy. For this reason, she expects these small practices will prefer EMR vendors that incorporate more functionality into their core products that accomplish the full set of meaningful-use objectives, including interoperability with HIE.

"Small practices will also be pressed to make EMR investments in the time frame for the ARRA subsidies, select and implement products, and evolve their clinical and business work flows to meet the criteria," Hanover contends. "This is a tall hurdle for practices that heretofore were paper based only.

"To meet all of the challenges of EMR adoption and get to meaningful use, it is clear that ambulatory providers need integrated solutions that address not only the total cost of ownership for the technology, but also the technology, work-flow and human-factor issues associated with EMRs," she says. "Addressing as many issues as possible in the solution will help to accelerate EMR adoption for providers and drive users toward both meaningful use and the quality and efficiency goals associated with EMR."

Many users surveyed by IDC indicate an approach to lessen the amount of process and work-flow change required is to carefully configure the EMR to the existing clinical-practice patterns. This approach has both advantages and drawbacks, Hanover explains. "While it may be advantageous for building acceptance of the technology initially, in the long term, failing to examine business processes can reduce the benefits from the EMR," she says. "Whether implementing new technology or not, it is beneficial for businesses to conduct periodic assessments of their processes and to seek out new efficiencies, and adjust processes to changes in their customers, requirements and the environment in which their business operates.

"Practices that do not re-evaluate at least some portion of their processes at the time of EMR implementation risk simply automating broken systems," she adds. "While they may gain some efficiency simply from the automation, there may be additional benefits that are foregone by failing to look holistically at the entire process."