Despite practitioners' growing interest in electronic medical records (EMRs) and the availability of many systems, most physicians still use paper-based medical records. In ophthalmology generally and in glaucoma particularly, a large amount of quantifiable data is well suited to recording and analysis in an EMR database. This article outlines some of the challenges and strategies you will face upon adopting EMRs as well as their many advantages for a glaucoma specialist. Our comments are based on our experience with NextGen software (NextGen Healthcare Information Systems, Inc., Horsham, PA). Like any other system, it has its distinct advantages and disadvantages, some of which we will outline here.
CHOOSING A SYSTEM
Surgeons should consider three main areas when selecting an EMR system. First, think about whether you want a system that allows easy customization. With such models, each doctor can see the information that he finds most important or most similar to his past techniques. Customization speeds up the examination, because the computer can bundle common activities together (eg, diagnosis, medication, patient handout, billing, etc.) into a single click of the mouse. The system adapts to the doctor more than the other way around, but the practice must actively participate in its customization and maintenance.
Second, make an educated guess about the stability of the vendor and its commitment to ophthalmology. Many attractive programs are produced by very small companies. With a smaller company that has fewer resources, your group may not be a priority for desired template modifications. Worse, if your vendor goes out of business, you could be stranded; you may not be a priority for modifications.
Third, be sure that your data are stored in an open (nonproprietary) format. You may then access your data using third-party software for mining data and generating reports, both of which will help you if your vendor goes out of business. Currently, open architecture does not mean that one program can read another program's data directly, but it does create the possibility of some transfer in the future.
CONVERTING TO EMRs
We tried several methods as each of our practice's doctors came on line. The most efficient approach was to train the scribe, reduce the doctor's schedule by approximately 20% for 1 week, and see all patients electronically beginning on a specific date. Trying to process a few patients or only new patients with EMRs led to bottlenecks and confusion.
The slowest part of the conversion is that every patient is initially new and needs a past medical history. We employed technicians in off hours and part-time students to enter the histories from old charts prior to most patients' visits. It was not as simple as scanning old information. For example, the computer can only check for potential interactions between medications if the drugs are actually entered into the system.
We chose not to automatically scan all the old notes and information from the paper charts into the system, although we had those charts available for each patient during our transition. For most patients, we found that we could write a three- to four-line summary that captured their necessary history (eg, diagnosis and date, initial and treated IOPs, severity of disease, rate of progression). Not scanning the entire paper chart saved a huge amount of time and labor, and we found that we were quite comfortable without it once the patient was established in the EMR system.
WORKFLOW
Templates
The EMR is based on a number of templates where data are entered to reflect findings on the patient's history, examination, testing, etc. After signing onto our system, we use a menu with "buttons" to access the various templates (Figure 1).
Additional buttons located on the individual templates help us to reach the most commonly used areas of the EMR. Most templates use pull-down menus or "pick lists," which contain choices for the most common responses or findings (Figure 2).
On our system, we can easily add or modify templates, and scarcely a week goes by in which at least one pick list or template is not altered. For example, we have recently added templates and triggers to streamline reporting and coding for the Physician's Quality Reporting Initiative.
New Patients
New patients necessitate the recording of a fairly large amount of information, particularly regarding their medical history and medications. If we receive their medical histories prior to their appointments, a technician enters the information into the system to save time on the day of the visit. If patients bring their medical history sheets with them to the visit and they have a long list of medical problems and medications, data entry can add 10 minutes to the initial workup. Once the information is in the system, however, workups for subsequent visits are faster than without EMRs and only require making periodic changes.
Personal Experience
When we enter the examination room, we usually look at an eye summary page that resembles a super-sized glaucoma flow sheet (Figure 3).
It contains virtually everything we need to know to care for a glaucoma patient, including a three- to four-line summary of his glaucoma history, the dates and findings of past procedures, visual acuity, IOP measurements, pachymetry readings, gonioscopic results, visual field tests, and results from optic disc imaging. We can also use buttons to find out about the patient's past use of ocular medications (including the agents' effectiveness, allergies, intolerances) and the glaucoma risk calculator based on the Ocular Hypertension Treatment Study-European Glaucoma Prevention Study predictive model.1
Most glaucoma specialists keep flow sheets containing some of this information in paper-based medical records, but a member of the staff must maintain and update them. With an EMR, information from the data fields is automatically loaded into the summary sheet and thus is always up to date. In addition, we can fit much more information onto the EMR's summary page, and all of it is visible while we are sitting at the slit lamp examining the patient. For example, if we notice that the patient's anterior chamber looks a little shallow, a quick glance at the computer tells us when we last performed gonioscopy and what the findings were. Similarly, at the conclusion of the examination, it is easy to determine what tests to order for the patient's next visit.
Findings
We document our findings using templates for the different components of the examination and for special testing such as visual fields and advanced imaging. All of the physicians in our practice use scribes, who enter the findings from examinations, the diagnosis, and procedural codes; print prescriptions and handouts; obtain drug samples; and escort the patient to the checkout desk. The cost of these scribes is paid many times over in improved efficiency and quality of care. The physicians are free to address patients' concerns while the scribes handle a variety of tasks in the background.
Communication
Virtually all communication is accomplished electronically in a fashion akin to instant messaging within our office network. Email messages include links to patients' charts, phone-message and billing templates, and any other pertinent part of the medical record. As physicians and staff complete and transmit these templates, they can simultaneously generate documentation of everything from phone conversations to requests for medical records.
We can respond to phone messages, answer questions on billing, and view consultation reports during the course of our clinical day without interrupting patient flow. Also, because we can view any patient's chart with Internet access alone, there is no need to transport charts to or maintain them at satellite offices. We can easily view charts from home. The server is secure and requires user login information. The home connection may not be secure as it is currently configured. Even if someone were able to access the data, they could not be usable/interpretable unless that individual was running a copy of NextGen and had our specific templates available.
VIEWING TESTS AND IMAGES
Many images—from visual fields to stereo disc photographs to computerized methods of optic disc analysis—must be incorporated into an EMR. For the past 6 years, we have viewed visual fields using the program Ensemble, which was originally to be a part of an all-in-one program from Carl Zeiss Meditec, Inc. (Dublin, CA), that would have allowed their various machines to interface with EMRs. This program was subsequently abandoned and is no longer supported. It had many useful features, however, including allowing users to toggle between a single field, an overview, and analyses of change at a computer in the examination room. We would print out on paper, view, and interpret scans with advanced imaging devices before scanning them into a document-viewing program that could be opened from within the EMR. We also scanned a copy of the visual field into this program as a backup to the computerized system. We will no longer be scanning in fields and images once we have new software (see below).
Finding a single program to handle all of the aforementioned types of images has been a challenge, particularly with regard to viewing visual fields. Some of the information contained in visual field tests is proprietary, which has hindered the ability of third-party vendors to develop viewing software. Nevertheless, there are a number of systems available, including those from Ophthalmic Imaging Systems, Inc. (Sacramento, CA), Anka Systems, Inc. (McLean, VA), and Digital Healthcare, Inc. (Wake Forest, NC). We have yet to find one that can replicate the functions of Ensemble (including the current program from Carl Zeiss Meditec, Inc.). We have recently installed OcuLab iP software from Digital Healthcare, Inc., which replicates some of the features of our old applications while also integrating the ability to view fundus images.
COSTS
The cost of transitioning to EMRs varies greatly depending on the system you select, the number of physicians using it, and the number and size of the offices involved, among other factors. Some of the costs of converting to EMRs are obvious (eg, software licenses, hardware, training, and support). Other expenses to consider include software and hardware for images and scanning, training staff and physicians, and temporarily reduced productivity. The initial outlay for our system was approximately $500,000, but this figure includes electronic practice management and EMR software plus hardware for 24 examination rooms and a number of other electronic practice management workstations. Additionally, the fee was shared by 10 physicians over 5 years.
Support-related costs approached $90,000 during our first year. We subsequently hired a full-time information technology person to work independently or with the vendor when necessary to troubleshoot problems when they arose. Our support-related costs have since dropped considerably, and having someone on site daily is convenient. Smaller practices that do not have sufficient need or resources to support a full-time information technology specialist could share such a person with another practice (either ophthalmic or another specialty) or work through a local vendor.
Although you should not expect to recoup directly all of the resources invested in converting to EMRs over the short term, you can anticipate significant cost savings over time, including an increased ease and efficiency of practice, more accurate documentation and coding, decreased costs of transcription, a lesser need for space to store paper charts, and, most importantly, superior care of patients. Certainly, an EMR system is not necessary to provide high-quality care, but we find it makes it much easier.
CONCLUSION
For the past 3 years, the annual meeting of the American Glaucoma Society has convened a special interest group that has focused on various aspects of EMRs. Although some attendees use these systems, most are still contemplating or preparing for the transition. The most common questions have been (1) Will it be too complicated? (2) Will it slow me down? and (3) Will it be too expensive? The short-term answer to all of these questions is yes. By choosing the right system and implementing it properly, however, EMRs can improve patient flow, the practitioner's and staff's quality of life, and the care of patients—all at a reasonable cost.
For additional information, visit www.visionassociates.net and click the education tab.
John C. Burchfield, MD, is in private practice at Vision Associates in Toledo, Ohio. He acknowledged no financial interest in the products or companies mentioned herein. Dr. Burchfield may be reached at (419) 578-2020; jburchfield@visionassociates.net.
Gerald G. Striph, MD, is in private practice at Vision Associates in Toledo, Ohio. He acknowledged no financial interest in the products or companies mentioned herein. Dr. Striph may be reached at jgstriph@visionassociates.net.
