HISTORICAL BACKGROUND
After hundreds of years of recording medical information on paper with techniques that have evolved very little since the invention of the fountain pen, the world is changing radically. The first electronic medical record (EMR) systems appeared in the 1970s but, until recently, remained less efficient than traditional paper records and were adopted by only a small percentage of eye care practices. Although the speed of a handwritten record is still difficult to replicate, modern technology now enables medical personnel to record and store digital data efficiently, cheaply, and with exceptional reliability and security. Most eye care practices in this country are now using an EMR system or are planning to implement one in the near future. This trend is partially driven by the federal government's financial incentives that are designed to encourage EMR adoption by all health care providers. This effort to modernize our health care system seeks to reduce overall costs and improve the quality of care provided to patients by minimizing the duplication of services and by facilitating communication between providers.
TECHNOLOGY
The dozens of EMR systems (also called electronic health records) available for eye care practices today differ significantly in their underlying technology. No two systems are engineered in exactly the same manner. All modern systems, however, fall into one of three basic categories:
Client-Server Systems
The majority of EMR systems currently available use
a “client-server” model. A server is simply a powerful
computer designed to store a large amount of data. In
an office setting, multiple computers, known as “clients,”
are linked directly to one or more centralized
servers located in the same facility. A copy of the software
application (EMR) resides on each individual client
as well as the server, but all of the data are stored on the
server.
Web-Delivered Systems
Many server-based systems now use the Internet to
allow users to access the application and data remotely.
The application (EMR) and all patient-related data reside
on a centralized server that may be located anywhere in
the country. Doctors and technicians in the medical office
connect to the server through the Internet. The advantage
of this model is that practices are not required to purchase
and maintain expensive server infrastructure. The downside
of this approach is that web-delivered (also known as
web-hosted) EMR systems are typically retrofitted clientserver
applications that were not originally engineered to
run across the Internet. Consequently, EMR systems that
are web-delivered require more Internet bandwidth and
may feel less nimble and responsive to the user.
Web-Based Systems
Most of the newest EMR systems are specifically engineered
to run over the Internet. These systems make use
of recent advances in technology that allow the application
to run directly within an Internet browser with
extremely low bandwidth requirements. The data reside
on a series of servers in a remote location. Large “server
farms,” often referred to as the cloud, house hundreds
or even thousands of servers that are linked together to
provide increased efficiency, redundancy, safety, and reliability.
All truly web-based EMR systems are also “crossplatform.”
This means that users are free to use any type
of computing device (desktop, laptop, or tablet) and
any operating system (Windows, Mac OS, Android, etc.)
when working with the EMR.
EMR COMPONENTS
The EMR allows users to enter and view clinical information about a patient. The user interface is that critical portion of the EMR that users actually see on the computer's monitor. A well-designed user interface provides the user with tools for efficient and intuitive data entry and presents information to the user in a format that allows for rapid assessment of the clinical situation. In addition to this basic functional requirement, an EMR should work in harmony with other software components to provide the user with an efficient and effective fully digital environment for patients' care. These other components are as follows.
Practice Management System
The business side of a medical practice
is primarily managed through the practice
management (PM) system. This is a software
application that manages patients' appointments,
billing, and accounts receivable. The
PM system sends patient demographics
and appointment data to the EMR. Then, at
the completion of a patient encounter, the
EMR sends coding data back to the PM system for billing.
Some software systems combine the EMR and PM systems
into one seamlessly integrated package. Others use
a strategy of integration wherein disparate EMR and PM
systems communicate through an interface.
Equipment Interfaces
A typical glaucoma practice uses multiple sophisticated
diagnostic technologies, including visual field analyzers,
optical coherence tomography (OCT), digital photography,
and many others to care for patients. The information
derived from these devices is critical to the quality care of
patients and must be readily accessible to the physician
during the encounter. The medical record must then permanently
and securely store the data for future reference.
With paper charting systems, this information is simply
printed and placed in the patient's chart. EMR systems that
rely on electronic data storage require a different strategy.
Some systems rely on scanners to create digitized images
of the printed material that are later uploaded to the EMR.
This is somewhat time consuming and results in nothing
more than an image of the clinical data. More sophisticated
systems use a digital interface that directly links the
diagnostic equipment to the EMR. This interface transfers
the clinical information to the proper location within the
EMR for viewing and permanent storage.
Image Viewing System
Most diagnostic devices in a glaucoma practice generate
images that provide meaningful information for
patients' care. These digital images (OCT, visual fields,
etc.) are displayed for the user by an image viewing system.
This is a software application that allows the user to
view and manipulate an image (zoom in and out), apply
annotations or notes to an image, draw on an image
when appropriate, and view multiple images simultaneously.
Some EMR systems have an image viewing system
seamlessly integrated into the application, whereas others
interface with a separately purchased product. The combination
of images shown in Figure 1 demonstrates the
value of an efficient image viewing system for the glaucoma
physician. The doctor can quickly toggle through disc
photographs from prior encounters to look for evidence
of disease progression while correlating those images with
OCT scans or visual field examinations.
Electronic Prescription
Modern EMR systems significantly improve patients'
care through the electronic transfer of medication and
allergy information. Virtually all EMR products accomplish
this by interfacing with an e-prescribe vendor that has
access to a national database of medical prescription and
allergy data. The e-prescribe vendor feeds information from
the national database to the EMR through an Internet
connection. Doctors then electronically submit new prescription
information from the EMR directly to the appropriate
pharmacy through the e-prescribe vendor. These
systems give doctors more accurate information about
their patients and reduce human error in the prescribing
process. Electronic prescribing is especially valuable for a
glaucoma practice in light of the large number of glaucoma
medications prescribed or refilled on a daily basis.
EMR-NOT JUST AN ELECTRONIC PAPER CHART
Novice users might suppose that an EMR is just an electronic version of the paper charts medical practices have been using for decades. In reality, the differences are profound because EMR systems introduce many concepts and principles that are unique to the digital environment.
Open and Closed Encounters
EMR systems clearly define the parameters of a patient's
visit to the eye doctor. The patient encounter begins when
a user electronically opens a new encounter for the patient.
Every data element entered in the record from that point
forward becomes part of that encounter. Users may enter
data as long as the encounter remains “open.” Once the visit is concluded and the encounter is
electronically “closed,” the EMR prevents
additions or changes to the record.
This is a legal rather than a technical
constraint. Most systems do allow the
creation of an “addendum,” if necessary,
after an encounter has been closed.
Copy Forward
Most patients' visits in a typical glaucoma
practice are “follow up” or established
patient encounters. Every technician
knows that much of the data that
must be recorded for each clinical visit
does not change significantly from one
visit to the next. This is one area where
EMR systems dramatically improve efficiency, because the
EMR automatically pulls much of that information forward
from the prior encounter and inserts it into the current
encounter. This usually includes problem lists, medications
and allergies, past medical and surgical history, and family
and social history. Some EMR systems also allow users to
“copy forward” the previous examination data into the
current examination. Although this feature is remarkably
efficient and saves considerable time, every user should
exercise extreme caution with this feature. The medical
record is a legal document and must accurately reflect the
information derived, or at least verified, during the present
encounter.
Data Summaries
Most EMR systems have the capacity to assimilate data
from multiple encounters and create a meaningful summary
of that data for analysis by the doctor. This is particularly
useful for the glaucoma patient, because the doctor
must critically analyze the progression of the disease over
time. The most commonly encountered example of this
type of functionality is the intraocular pressure (IOP) graph
(Figure 2). The EMR automatically collects and graphically
displays a patient's IOP readings from every prior encounter.
Almost any data element (visual acuity, refraction data,
pachymetry, etc.) can be tabulated and displayed in summary
form. EMR systems that present doctors with this
type of summary data significantly enhance the efficiency
and quality of patients' care.
Coding
Every eye care practice relies on proper coding at the
conclusion of an encounter in order to generate a bill
for services rendered. The coding process is exceedingly
complex with thousands of possible combinations of procedural
codes, diagnostic codes, and modifiers. Most EMR
systems employ some form of coding “engine” that analyzes
the data entered during the encounter. The engine then
generates a coding suggestion to guide the doctor toward
a proper code. Coding engines coupled with an EMR system
can increase coding accuracy, maximize revenues, and
reduce the risk of inadvertent overcoding.
The Audit Trail
Medical offices that utilize paper charts require users
to sign or initial entries in the chart so that others
can tell who recorded that information. EMR systems
require each individual user to log in with a password
before reviewing or entering data. The user's identity is
then automatically linked, along with the date and time,
to every data element entered throughout the encounter
even though this linkage process may be invisible to
the user. This information becomes a permanent part
of the medical record's “audit trail.” Technical personnel
can retrieve the data when necessary.
THE OPHTHALMIC TECHNICIAN'S ROLE IN EMRs
Ophthalmic technicians interact with EMR systems throughout the course of most patient encounters. Consequently, every technician must become familiar with the user interface and data entry strategies of the EMR system in order to record patients' data quickly and efficiently. No technician can do that without a thorough knowledge of the EMR system being used. Although some EMR systems are more challenging to learn than others, even the best designed, most intuitive systems still require the investment of time by a potential user. Most EMR vendors provide some form of training environment that allows users to practice while utilizing data from fictitious patients. Focused practice with simulated patient encounters prior to “going live” with real patients is time well spent. An ophthalmic technician who is comfortable with the EMR system can focus on patients' care rather than on a computer screen. A well-trained, efficient, and productive technician is an enormous asset to any eye care practice, especially when the practice is embracing the future by transitioning to a modern EMR system.
