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Quality management in ambulatory care: the future is now.

In the last half of the '80s, there was increasing talk about quality in the ambulatory environment.(2,3) Unfortunately, the incentives for quality were weak and we ended up with more "talk than walk."

The '90s will be different. The external forces described so well by Fred Jones elsewhere in this issue are beginning to have a major impact on ambulatory care. Quality is suddenly high on our agenda. The purchasers of care are in charge now and they want quality. They understand that quality begins at the ambulatory visit.

Although hospitals are ahead of us on the quality scene, what is currently happening in the hospital setting will soon become "real world" activity in the ambulatory environment. The quality initiatives that are, happening are, for the most part, brand new to ambulatory care. We have only dabbled with them in the past.

The talk on the hospital side is about actual measurement of quality, data-driven clinical decision making, practice guidelines, outcomes, customer orientation, process improvement, and value. These are new words in ambulatory care, but they are destined to become part of our vocabulary.

The era of the "bad apple" is over. With good reason, physicians have resisted quality assurance in the past. Our response has been "fight or flight." The new quality management approach is a breath of fresh air. It will take ambulatory care practitioners a while to internalize this new philosophy and to trust the quality people once again. Once this happens, ambulatory care physicians will lead the charge--not only toward the new vocabulary, but also toward the way of doing things that the new vocabulary represents. Measurement, data, guidelines, and outcomes make sense. Although occasionally it has been a well-kept secret, physicians are sensible. Physicians will get on board in the ambulatory setting and help to make all of this happen.

The Ambulatory Quality Obstacle Unfortunately, there is a huge problem that has the potential to delay by years the movement toward quality in ambulatory care. A few of the larger ambulatory organizations (large group practices, managed care organizations, and large hospital ambulatory programs) may not be limited by this problem; the rest of us will.

In ambulatory care, we have watched with great interest, increasing satisfaction, and no small degree of consternation the increasing prominence of ambulatory care.(4) We have noted the greater respect now being accorded primary care. Ambulatory care visits are increasing at an astounding rate. Many of us over the past decade have been cranking out as many ambulatory patient visits as we possibly could. We are now being subjected to increasing pressures for more visits. Our machinery (systems and processes) is "maxed out." It is creaking and groaning. We desperately need to improve our processes so that we can deliver an even higher volume of patients with resources that have become even more strained. To this demand for increased visits has been added the responsibility of defining, measuring, and documenting the quality of our activities.

Process improvement (by whatever name it is called) will work, but it takes time. The time is measured not in weeks or months but rather years. Outcomes, guidelines, chart reviews, data collection, and total quality management are good ideas, and we will have to do these things. External forces are increasing the pressure. Right now though, it is all that we can do with the resources available to get a patient in the front door and out the back in a reasonable amount of time. These quality initiatives are a major logistical problem for us. We have neither the time nor the resources for them.

The Great Enabler

Fortunately, there is a great enabler on our horizon. The single most important contributor to quality in ambulatory care in the '90s will not be practice guidelines or continuous quality improvement. It will be the ambulatory electronic medical record.(5,6) We are not talking here about continuous small incremental improvement (good as that may be). With the electronic medical record, we are looking at a great leap forward. The electronic medical record will enable those of us in ambulatory care to do the kind of quality-related activities that need to be done in our environment of rapidly increasing visits in spite of less than compensating resources.

Quality management in ambulatory care will be enabled, assisted, supported, and encouraged by the electronic medical record. In ambulatory care, we have had to wait our turn. The hardware people first focused on hospitals and then turned their attention to ambulatory care. The software people have done the same. In addition, the software people started with the business side of our activity. They are now turning their attention to the quality side. The technology necessary for electronic medical records has either arrived or is arriving. Memory is no longer a problem. One compact disk can store more than 250,000 pages of medical records. Speed is no longer a problem. Networking is no longer a problem. Scanning, networking, voice activation, and touch-screen technology have all arrived on our scene. The price is reasonable and affordable. Nearly all of us already have computer systems. We are talking here about an add-on. And it is an add-on that will change the face of ambulatory care.

Ambulatory Electronic Medical Records

With electronic medical records, we will have medical records that are always legible and have uniform content and format. A problem for the quality people now in ambulatory care is finding data in the record. Legibility in many cases is borderline. At best, data often are not where they are supposed to be. The computer is more compulsive than any human being. If we enter them correctly, the data will be where they are supposed to be.(7)

The problem list and medication record can be done automatically. The Joint Commission has led us, for the most part kicking and screaming, into the era of a problem list and medication record on each ambulatory chart? They are both good ideas. They have remarkable potential to affect continuity of care. Unfortunately, they have never worked well. We have never been clear about what to put on problem lists and medication records. We have never had 100 percent buy-in from practitioners. Many think the trouble exceeds the value. Even the best-intentioned practitioner forgets on occasion. Problem lists and medication records are not dependable. The electronic medical record can create these lists for us automatically. Whether we like it or not. Whether we remember or not. If we mention our diagnosis to the computer, it will make certain that the diagnosis makes the problem list. The same is true with medications and the medication record.

The electronic medical record can link to pharmacy software packages. It can tell us if we are about to prescribe a medication with significant interaction with other medications. It can remind us about medication sensitivities. It can remind us about medication's used previously. It can keep track of all medications a patient is currently taking.

One of the major benefits of electronic medical records in the ambulatory setting is the potential to build in reminder and follow-up systems.(9) Things are always falling through the cracks. We plan to repeat the potassium in six months. Sometimes we do, often we forget. The computer won't forget. The electronic medical record can remind us about health promotion, disease prevention, and periodic health maintenance activities. It can follow up on appointments not kept, on consultation reports not back, and on abnormal laboratory data not dealt with. In ambulatory care, where continuity and compliance are such major factors, the electronic medical record can provide a major assist.

We can build practice guidelines into the electronic medical record. Tell the computer the symptoms, the signs, or the diagnosis, and it can remind us about the relevant practice guidelines. It can even prompt us if we are not following the guidelines. Now our guideline feedback is retrospective. With electronic medical records, the potential is there for feedback to be concurrent. The computer interaction and prompting can be happening while we are seeing patients.

Outcomes measurement is a real problem in ambulatory care. For the most part, we have no idea what kind of outcomes we are achieving. The electronic medical record offers the potential to track outcomes for us. It can track outcomes corrected for various acuity factors. Health status index measurement can also be included.

Chart review in ambulatory care is a hugely expensive endeavor. Even a five percent sample takes a horrendous number of practitioner hours-- not to mention the hours invested in pulling and refiling the charts and processing the data. The electronic medical record can do a 100 percent sample in a fraction of the time.

The electronic medical record offers the potential to network laboratories, radiology services, and other consultants. Data can be transmitted electronically. Reports won't get lost in the mail. They can be instantly available.

In the ambulatory setting, taking night call is potentially a very high-risk activity. Often, we are talking to patients we don't know, and we make our judgments totally on the basis of what the patient tells us, with no medical record in front of us and no patient to examine. A modem will enable us to access the electronic patient record at home. We will know what is happening. We will know the patient's diagnoses and what medications have been prescribed. A significant increase in the quality of this telephone interaction will occur.

The phenomenon of networking to develop a reference database is already beginning, primarily in the hospital setting. Networking electronic medical record systems will make it possible to develop a functional and efficient reference database for ambulatory activity.

Impact on Quality Management

All of these enhancements will contribute to a remarkable increase in ambulatory care quality.(14) But they will also contribute to a remarkable increase in our ability in ambulatory care to manage quality. Practice guidelines in ambulatory care will no longer be a huge problem; they will be a huge benefit. Measuring quality will no longer be an impossible dream; it will be done electronically on a daily basis. Outcomes measurement will no longer be a hazy mirage of wishful thinking; it will be clear, precise, and available on a daily basis. Continuous quality improvement will no longer be frustrated because of lack of data; the data will be there for the asking. Process improvement teams will become highly efficient. Quality indicators will no longer be ominous, and quality assessment will no longer be a chore. All will contribute to more efficient quality management, more effective quality, and healthier patients.

The '90s will be a decade of much quality management activity in ambulatory care. Total quality management and continuous quality improvement are good ideas. We need to adopt them in ambulatory care with as much enthusiasm as they are being adopted in the hospital setting. The great enabler will be the electronic medical record. Good software packages are now available. Many others will be on the scene shortly. We need to take this phenomenon very seriously, explore it very carefully, and then begin to move with optimism in its adoption. Electronic medical records will make ambulatory quality management possible.


1. Percy, L. "The Quality Process. Hospitals Begin to Emphasize Quality in Devising Strategic Plans." Modern Healthcare 18(14)30-4, April 1, 1988.

2. Palmer, H. "The Challenges and Prospects for Quality Assessment and Assurance in Ambulatory Care." Inquiry 25(1):119-31, Spring 1988.

3. Tyler, R. "Quality Assurance in the Ambulatory Care Setting." Physician Executive 15(6):17-20, Nov.-Dec. 1989.

4. "Outpatient Care Is 'in.' Ambulatory Accreditation Grows." Group Practice Journal 39(1):44-5, Jan.-Feb. 1990.

5. Norman, L., and Hardin, P. "A Multipurpose Computer-Assisted Program to Improve Ambulatory Medical Care: A Preliminary Report." QRB 16(10):365-72, Oct. 1990.

6. Anderson, J. "Computerized Medical Record Systems in Ambulatory Care." Journal of Ambulatory Care Management 15(3):67-75, July 1992.

7. Mcdonald, C., and Tierney, W. "The Medical Gopher--A Microcomputer System to Help Find, Organize, and Decide about Patient Data." Western Journal of Medicine 145)6):823-9, Dec. 1986.

8. Benson, D., and others. "Quality Ambulatory Care: The Role of the Diagnostic and Medication Summary Lists." QRB 14(6):192-7, June 1988.

9. McDonald, C., and others. "Reminders to Physicians from an Introspective Computer Medical Record. A Two-Year Randomized Trial." Annals of Internal Medicine 100(1):130-8, Jan. 1984.

10. Benson, D., and Reimlinger, G. "Electronic Medical Records in the Ambulatory Setting: The Quality Edge." Journal of Ambulatory Care Management 14(1):78-87, Jan. 1991.

Dale S. Benson, MD, FACPE, is Director, Ambulatory Care Services, Methodist Hospital of Indiana, Inc., Indianapolis.
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Article Details
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Author:Benson, Dale S.
Publication:Physician Executive
Date:Nov 1, 1993
Previous Article:What's ahead on quality: the managed care perspective.
Next Article:The marriage of medicine and computers.

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