Hospital versus clinic EMRs: what’s the difference?

By Shawn Vincent

I consider myself a very lucky individual. I’ve had the privilege of working on building EMR products both in hospitals as well as smaller clinics. When I first moved from the world of hospital EMRs to the world of clinic EMRs, I was not surprised by the similarities between the two worlds. What surprised me were the differences. There are several profound differences that I’ve observed that have profound impacts on the way EMR software is built and used.

In some ways, healthcare is healthcare. The cycle of care is universal: patient gets sick, which spawns a cycle of assessing, testing and treating until the patient gets well or worse, dies. The fundamental activities of assessing, testing and treating the patient are very similar in the hospital and clinic world – but there are some key differences.  

Difference 1: Need for Speed

Hospital: The hospital cares for the sickest patients. Minutes (or sometimes even seconds) can make the difference between life and death.

Clinic: In a clinic environment, patient care is measured in weeks, not hours. Clinics care for the chronically ill and non-emergent cases. There is much less time sensitivity than in a hospital environment.

Consequence: In the fast-paced hospital environment, live access to results as soon as they become available are critical. However, if a patient’s appointment can only be booked 3 or 4 weeks after the test is scheduled, the need for live results is dramatically diminished.

Difference 2: When does the patient leave?

Hospital: In a hospital, patients consume beds and resources until they are discharged. They can’t be discharged while tests and treatments are outstanding. This means that following up on a test or a treatment is critical to efficient running of the organization.

Clinic: In a clinic, the patient leaves after their visit with the doctor. No resources are being consumed at the clinic while tests and treatments are outstanding. Following up on a test or a treatment improves care, but does not dramatically reduce costs to the clinic.

Consequence: Hospitals have a greater need for round trip test and treatment management than do clinics: it is a key cost saving measure. I suspect that this need is the prime reason why hospitals computerized years before smaller clinics did.

Difference 3: Who is responsible?

Hospital: Hospitals are not usually run by doctors (the recent Grey’s Anatomy storyline notwithstanding). They are large organizations that have boards of directors, business and medical records experts, lawyers, and dozens of other stakeholders that need to agree on policy.

Clinic: in a traditional clinic, the doctors are also the business owners, ultimately responsible for not only the patient’s care, but also the documentation, the billing, and the ultimate liability.

Consequence: In the larger hospital environments, there are often stringent rules about how medicine is practiced and documented. In smaller clinics, the doctors decide.

This has many consequences, all the way from the user interface implications of controlling how documentation is captured, right through to decisions about what events gets audited.

Difference 4: Episodic versus Longitudinal Care

Hospital: Hospitals mostly practice acute episodic health care. Encounters are profound. Many staff in a hospital don’t want to see information from encounters other than the current one.

Clinic: In a clinic environment, long term (often known as longitudinal) care of the patient is critical. Chronic diseases are the classic example. Knowing how the patient is progressing year to year can make a profound difference.

Consequence: This one is near and dear to my heart, since I’ve worked on user interfaces in both the hospital and the clinic environment. Trying to design a user interface that shows just enough information to make a meaningful medical decision without distracting the user with unnecessary details is challenging. Knowing whether cross-encounter visualization is important is a key design factor that has great implications.

Difference 5: Availability of IT services

Hospital: Hospitals are large organizations that can often afford IT services. These resources can help to customize and configure a system to make it more effective.

Clinic: Many small clinics simply do not have the resources to do extensive workflow analysis or software customization.  

Consequence: Most clinics require some degree of workflow customization. However, when building software for small clinics, it’s important to remember that these smaller clinics don’t have unlimited budgets (time or money) for customization. A product that works right out of the box and possibly offering professional services to customize the solution as necessary are critical.

Why is understanding these differences important?

These differences are getting more important in recent years, due to three factors:

First: The lines between “hospitals” and “clinics” are becoming blurred. In Canada and around the world, we are seeing many new models of health care, many of which are hybrid solutions – large organizations run like hospitals with clinical staff as employees rather than owners. These organizations share many of the traits of hospitals and the small clinics. Understanding the differences between these environments can be key to user acceptance and world class systems.

Second: Hospitals are further ahead in the push to integrate technology into health care (largely due to the need for speed and the fact that patients consume resources until discharged). This means that the experts in Healthcare IT (HIT) are predominantly from the hospital space. Often the unique needs of clinics are ignored or forgotten when solutions are delivered to smaller clinics.

Third: Integration brings these issues to the foreground. We are increasingly seeing hospital systems and clinical systems being integrated. This brings the two cultures together, often using the same computer systems. Designing such joint systems and interfaces involves balancing the needs of the two different user communities. Understanding the differences in the cultures becomes critical.

These are a few key differences that I’ve seen in my time in this industry. I’m sure there are subtleties I’ve missed that clinical experts who live their lives in these worlds could point out.  

Do you know of other key differences between hospital and clinic environments? Do you think I’m way off base with any of the differences I’ve seen? I’d like to hear from you. Send me an email at shawn.vincent@telus.com.

Shawn Vincent is Director of Development at TELUS Health.

Posted May 9, 2013