Bad, Ugly and Good: Implementation of an Electronic Medical Record in Ambulatory Care

Purpose:
We plan to describe what worked best (the good), what did not work (the bad and ugly) and what we would recommend for others in ambulatory care settings who are planning to implement an EMR.

Significance:
The EMR is a significant strategy to enhance patient safety, monitor quality and enhance interdisciplinary communication. The EMR requirement by the Accreditation Council for Graduate Medical Education (ACGME) was essential for ongoing education of medical residents practicing in our setting.

Strategy and Implementation:
The strategy for implementation required coordinating schedules for 39 residents and 39 clinic employees for the nearly 1000 monthly client visits. Our challenges included a timeline for implementation that coincided with the annual new resident orientation, significant department construction and redesign, budget constraints, as well as the need to assure no interruption to clinic client services. Significant time for preloading all client data prior to the go-live date was an important consideration. The vendor-developed education required changes for our setting. Education was developed for registration clerks, billing and coding specialists, medical assistants, nursing staff, resident and attending physicians. Implementation delays resulted in development of reference materials for ongoing education. The nursing management partnership with our shared governance practice and research council was an important strategy for the successful implementation.

Evaluation:
Results include streamlined education for new physician residents and improvements in nurse and staff satisfaction. Customer service has improved through quick access to patient requests for information. Patient photos and legibility have enhanced both patient and staff safety.

Implications for Practice:
Clinician and end-user involvement for EMR planning is essential for a smooth transition from a paper format. Role changes and new skills will be needed by all staff. The staff-management partnership and networking with experienced EMR users will facilitate implementation and improved outcomes.