EMRs for the Glaucoma Doctor

Can an electronic medical record really help your practice?

By Kyle H. Smith, MD and John C. Burchfield, MD

If you feel skeptical about implementing an electronic medical record (EMR) system in your practice, you are not alone. A great majority of ophthalmologists share your concerns about the potential for an EMR system to help their practice in any meaningful way. You may have heard that 50% to 80% of EMR implementations fail and that these efforts are more prone to failure in ophthalmology practices than in other specialties because of the high volume of patients and data-intensive nature of eye care.1 Given the poor track record, you may have concluded that an EMR system will be just another bitter pill to swallow when government regulations finally force you to take your medicine or face the financial penalties for noncompliance.

As you walk through the graveyard of EMR failures, you do not need to be a brilliant diagnostician to determine the cause of death in most cases. EMR systems that fail generally do so because they undermine efficiency in the practice.2,3 Inefficiency kills productivity. Who cares about the $44,000 Health Information Technology for Economic and Clinical Health (HITECH) Act incentive for using an EMR when your practice is 10% to 20% less productive? Even worse, an inefficient system may also decrease the quality of patients’ care. No patient wants his or her doctor’s attention to be dominated by a computer screen for the entire visit.

Despite these valid concerns, it will behoove you to keep an open mind when considering EMR systems.

Not an Electronic Paper Chart
A common misconception among doctors who are anticipating making the switch from paper charts to an EMR system is that the latter should look and function just like the former. In reality, such an EMR system would be terribly inefficient and could never achieve the full potential of electronic data storage and manipulation. EMRs are a completely new paradigm in documenting encounters with patients. By allowing EMR design to break free of the traditional model of paper charts, the potential for efficiency and quality far exceeding that of paper records can become a reality. New technology coupled with enhanced, efficiency-focused, eye care-specific EMR designs is finally bringing the promise of EMRs into real-world clinical practice.

User Interface Design
The design of the user interface is the single most important element in an EMR system’s adoption by doctors and staff. The fundamental requirements of an efficient user interface are data entry, data assimilation, and task management.

The EMR system must allow quick and efficient data entry throughout the encounter, without undue reliance on typing, lengthy pick lists, or excessive mouse clicks to accomplish a task. A larger challenge is the need for doctors to document their thoughts about their patients as efficiently as possible. Doctors are paid to think, and their thought processes are the most important information in the record. Some EMR systems deal with this challenge by using customizable blocks of text (macros) that are created, saved, and imported as needed.

A truly efficient EMR system will present data to the user with intuitive formatting that anticipates the user’s thoughts and needs. A key concept in efficient user interface design is the elimination of visual “noise.” Users presented with too much information on a screen will waste time searching for that one piece of information they really need at that moment.

Finally, the user interface must facilitate the various tasks that users need to accomplish in every encounter with patients. An EMR system designed to maximize efficiency will quickly generate forms, letters, orders, and prescriptions. It will help keep the entire team on task and well organized.,/p>

Finally, the user interface must facilitate the various tasks that users need to accomplish in every encounter with patients. An EMR system designed to maximize efficiency will quickly generate forms, letters, orders, and prescriptions. It will help keep the entire team on task and well organized.

Diagnostic Equipment Interfaces
The sheer volume of clinical data generated by sophisticated diagnostic devices is another major challenge for EMR systems, particularly in a glaucoma practice. The vast majority of diagnostic devices in use today were not designed to send data to an EMR system. Instead, they send data to a printer so that a paper document can be incorporated into the patient’s chart. Scanning those documents and then uploading the files into the EMR system is somewhat inefficient and time consuming. Fortunately, new technology is allowing successful and efficient data transfer from these units directly into EMR systems. Most newly manufactured diagnostic devices are designed with network interfaces that facilitate integration with EMR systems.

Good physicians are always seeking means by which to provide better care to their patients. Can an EMR system help you in this regard? Systems that fail to clear the efficiency hurdle also tend to sacrifice quality care. A well-designed user interface that allows a user to work with great efficiency, however, can also significantly improve patients’ care.

Access to Information
Doubtless, you have faced the frustration of having to make a clinical decision without full access to data that might have made a difference in that decision. In a world where information is king, the ability to access clinical data electronically is a fantastic advantage. Electronic data are instantly accessible and are rarely lost or filed incorrectly. Internet-delivered systems provide the additional advantage of access from anywhere at any time.

Summary Screens
The true value of a summary screen in an EMR system is its ability to present the user with a longitudinal analysis of information. This is critical in glaucoma care where an analysis of multiple data points over the course of time is essential for assessing and managing the disease. Unlike paper chart systems where these data points require time-consuming manual entry on summary documents, an EMR system can automatically pull the relevant data from each encounter and present it to the user in a meaningful, visually comprehensive format (Figure 1).

Image Viewing System
Most EMR systems are equipped with some sort of an image viewing system that allows efficient viewing and interpretation of digital images. The glaucoma doctor can quickly scan through a series of visual fields, disc photographs, optical coherence tomography examinations, or other glaucomarelated studies (Figure 2). Newer monitors provide higherresolution images than printed copies. Monitors that permit stereoscopic analysis of disc photographs will soon be commonplace.

Care is always enhanced when providers communicate effectively about their mutual patients. Most EMR systems allow the user to generate letters to primary care physicians, referring physicians, and other providers with only a few mouse clicks. These letters may be printed and mailed or transmitted electronically over the Internet.

Error Prevention
Systems that allow automated data entry from diagnostic devices and electronic prescription services minimize the potential for human error.

Even if an EMR system has no positive effect on the number of patients you see in a day, many financial benefits could still more than offset the cost of this technology. These include

  • HITECH Act reimbursement
  • Improved compliance with the Physician Quality Reporting Initiative
  • Proper coding (eliminate undercoding)
  • Reduced office staff (no paper charts to manage)

Perhaps you are still skeptical. Fair enough. Selecting and implementing an EMR system is a huge decision for your practice. You will do yourself and your practice a favor, however, if you keep an open mind and continue to search for the perfect EMR system for your situation.

Kyle H. Smith, MD, is the president and CEO of Integrity Digital Solutions, LLC. Dr. Smith is also the chief of the Division of Neuro- Ophthalmology at Scott & White Eye Institute in Temple, Texas. He holds a financial interest in Integrity Digital Solutions, LLC, and its EMR product, Integrity EMR for Eyes. Dr. Smith may be reached at (254) 718-7250; ksmith@integrityemr.com.

John C. Burchfield, MD
Electronic medical record (EMR) systems lend themselvesreadily for use in caring for glaucoma patients and can greatlyimprove the efficiency and quality of care. In his article, KyleSmith, MD, nicely outlines some of these advantages. I wouldlike to focus on three of the most important in a glaucomapractice.

Access to and Assimilation of Data
Managing glaucoma patients requires the assimilation andcoordination of much information in the form of examinationfindings and test results. In paper charts, this task has traditionallybeen accomplished through the use of flow sheets that displayIOP readings, optic disc measurements, gonioscopic findings, pastdiagnoses and procedures, etc. Flow sheets, however, requiremanual updating, they are limited in what they can hold, andinformation is sometimes incomplete. Moreover, the sheets canbecome lost or damaged. EMR flow sheets have the advantagesof being updated automatically and being much more flexibleand complete in their content.

In my practice, an eye summary page (Figure 1) contains virtuallyevery piece of information I need to make a decision regarding aglaucoma patient’s care. Most is displayed for view on a singlepage, and other pages can be accessed with a single click of themouse. All of this information except the eye history is loadedautomatically from data fields in other templates. The eye historybox summarizes pertinent information, either taken from the oldpaper chart or entered the first time a patient is seen. In convertingfrom paper to EMRs, clinicians will find that the relevant historycan be distilled down to four or five lines for the vast majority ofpatients, regardless of the size of their charts. I therefore stronglyrecommend against automatically scanning all paper charts intoan EMR system.

In our relatively large practice (12 MDs and two ODs) withmultiple offices and subspecialists, many of our patients receivecare from two or more doctors in the group. Using EMRs, consultations and notes on patients are e-mailed between physicians,greatly facilitating the coordination of care. Phone calls aredocumented in specialized templates that are linked to patients’charts and are e-mailed from the staff to the physician and back.This setup makes it easy to answer questions in real time withoutdisrupting the flow of patients.

Access to Charts
Being able view a chart from any location with an Internetconnection is of tremendous benefit when caring for patientswho are seen at multiple sites. It is also a great help to an on-calldoctor needing to access a patient’s record in order to handlequestions and problems during off hours.

I have not listed diagnostic equipment interfaces and testanalysis as strengths of an EMR system. The cost of obtainingEMR interfaces for each piece of equipment and/or a third-partyprogram for handling this information can be significant, andviewing serial tests and images is sometimes cumbersome. Physicianshave powerful statistical tools for analyzing visual fields attheir disposal. This potential has yet to be realized across all visualfield platforms, however, where clinicians have been forced inlarge part to use visual field images rather than the actual numericaldata. Physicians’ ability to manipulate visual field output at anexamination room’s workstation has been limited or nonexistent.

Haag-Streit USA, Inc. (Mason, OH), has introduced perimetrysoftware (EyeSuite) that allows the user to vary graphical outputand view statistical analyses on demand in the examinationroom without additional manipulations of output on the visualfield machine.1 It is to be hoped that other manufacturers willfollow suit.

The best way to summarize the advantages of EMR systemsin caring for glaucoma patients is not to state that they willincrease collections or make a practice more efficient,although they may do both of those things. Rather, EMR systemsmake it easier to improve the quality of care and thuspractitioners’ and the staff’s quality of life as it relates to thepractice of ophthalmology.

John C. Burchfield, MD, is in private practice withVision Associates in Toledo, Ohio, and he is an assistantclinical professor of ophthalmology at theUniversity of Toledo Medical Center. He acknowledgedno financial interest in the products or companies mentionedherein. Dr. Burchfield may be reached at (419) 578-2020;jburchfield@visionassociates.net.


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