April 27,2004, President George Bush announced a goal to establish electronic health records (EHRs) for all citizens within a 10 year time frame. In July, Health and Human Service Secretary Tommy G. Thompson, announced the “Decade of healthcare Information Technology” and announced the publication of a report which reveals how vital it is to have automation in the physician’s and ambulatory offices.

                The report identifies four major goals, with strategic action areas for each (Decade, 2004):

  •    GOAL 1: Inform Clinical Practice.
        -   Bringing information tools to the point of care, especially by investing in EHR systems in physician offices and hospitals.
  •  GOAL 2: Interconnect clinicians.
    -   Building an interoperable health information infrastructure, so that records follow the patient and clinicians have access to critical health care information when treatment decisions are being made.
  • GOAL 3: Personalize Care.
        -   Using health information technology to give consumers more access and involvement in health decisions.
  • GOAL 4: Improve population health.
        -   Expanding capacity for public health monitoring, quality-of-care measurement, and bringing research advances more quickly into medical practice.

Applications Necessary in the Ambulatory Environment

                The applications needed in the ambulatory environment are similar to those required in the in-patient arena.

Major application Areas:

                                Registration                                          accounts payable

                                Billing                                                    patient and staff scheduling

                                Accounts receivable                            managed care functionality

                The benefits that can be achieved by using electronic records encompass the financial, administrative, and clinical areas.

Financial Benefits

Cost effective and timely bill submission process resulting in decreased days in accounts receivable and the reduction of rejected claims. Client benefits need to be verified and accurate insurance information obtained.

 Larger ambulatory care organizations use electronic data interchange (EDI) to automate the exchange of data (typically between providers and payors) such as claims, submittals and remittances, and health plan eligibility information.

Some organizations also provide intergrated credit card payment applications so that patients may use credit cards, which are processed immediately.     

      Administrative Benefits

Administrative benefits of implementing an automated information system: reduction in size of the record room, reduced time spent finding and delivering charts, increase in the privacy of data, formats that are legible and comply with legal regulations, the promotion of quality assurance, improved patient satisfaction, ability for home access by physicians and nurse practitioners, alerts for incomplete data, and the intergration of clinical data.

      Clinical Benefits

Clinically, the automated healthcare record can provide a problem list, automated ambulatory care provider order entry (ACPOE), a medication record, vital signs, progress notes, results from the laboratory and radiology departments, flow sheets, growth charts, immunization records, medication allergies, profiles, alerts and reminders , a follow up system, clinical decision support system, e-Prescribing, and evidence-based medicine.

                                                A patient master index, is the basis for collection of all patient related data.

                A master patient index, is a central repository for patient/member information across the enterprise including sophisticated tools for querying, updating, and managing the index. It must be able to accommodate multiple patient identifiers so that different locations can maintain their current medical record identification system. The registration system collects patient demographics and insurance information.

Other functions of ambulatory care environment can be enhanced by electronic information technology for data collection and management; and referrals.

Regulatory Requirements

Accounting for costs can be aided by information technology. Systems must support the resource based relative value scale (RBRVS) and the relative value unit (RVU). The RBRVS procedure fee pricing is a model designed by the Department of Health and Human Services (DHHS). In this system, each physician’s current procedural terminology (CPT) code has a relative value associated with it. The payor will pay the physician on the basis of a monetary multiplier for the RVS value.

The Ambulatory care arena, just like other healthcare sectors, requires data in order to manage care. The Health Care Portability and Accountability Act of 1996 requires six code sets. Such as:

      Current Procedural Terminology (CPT)

                  Describe medical procedures performed by physicians and other health providers.

      Ninth Revision of the International Classification of Diseases (ICD-9-CM)

It is designed for the classification of morbidity and mortality information for statistical purposes, for the indexing of hospital records by disease and operations, and for data storage and retrieval.

      Healthcare Common Procedure Coding System (HCPCS) or (HCFA HPCS)

It is a collection of codes that represent procedures, supplies, products and services which may be provided by Medicare beneficiaries and to individuals enrolled in private health insurance programs. The codes are designed to promote uniform reporting and statistical data collection of medical procedures, supplies, products and services. 

      National Drug Code (NDC)

                                                It identifies pharmaceuticals in detail including the packaging.

      Code on Dental Procedures and Nomenclature

             Medicare’s ambulatory payment classification (APC)
                  It is a prospective payment system for hospital outpatient services.

            Health plan employer data and information set (HEDIS)
             It is a standardized, comprehensive set of indicators used to measure the performance of a health plan.

         Outcome and Assessment information set (OASIS)
                    Regulations for home care industry. Is a data set for use in home health agencies and is an initiative from the Health Care Financing Administration. The purpose is to provide a comprehensive assessment for an adult home care patient and measure patient outcomes for purposes of outcome-based quality improvement.

Member Associations Involved in Ambulatory Care

                Major Ambulatory care organizations:

            The American Academy of Ambulatory Care Nursing (AAACN)

            The American Medical Informatics Association (AMIA)

            The Medical Group Management Association (MGMA)

            The Society for Ambulatory Care Professionals

            The Federated Ambulatory Surgery Association (FASA)

            The American Association of Ambulatory Surgery Centers (AAASC)

            The Association for Ambulatory Behavioral Healthcare

            American Health Information Management Association (AHIMA)

            Healthcare Information Management Systems Society (HIMSS)

      Local (California, US) Ambulatory care organization:

            Ambulatory Information Management (AIM)

Accreditation Organizations

      Accrediting organizations validate standards of practice and promote quality care. Examples such as:

                Accreditation Association for Ambulatory Health Care (AAAHC)


      The National Committee for Quality Assurance (NCQA)

      The Joint Commission on Accreditation of Healthcare Organizations