Switching to Electronic Medical Records
Moving into the electronic age can be a daunting task. Here's helpful advice from an expert.
By U. Fusan Cardakli, M.D., Altoona, Pa.

In today's challenging ophthalmology environment, money is tighter, legal issues and government regulations are more pervasive, and the threat of an audit is greater than ever. As a result, electronic medical records (EMR) have attracted increasing interest, both because they promise to expedite and simplify recordkeeping and because they may offer better protection against legal liability.

Electronic medical records have a number of advantages over traditional paper records, including uniform and complete documentation, ease of use, automated generation of letters, prescriptions and other documents, instantaneous access from multiple locations, and data searching capabilities.

Despite these advantages, many doctors have reservations about switching to EMR -- especially those doctors who have little experience with computers. Common concerns include:

• Will the system really meet our needs?
• Will it take forever to learn to use it?
• Will it interface with our other equipment?
• Will making the switch from paper records to electronic disrupt our practice?
• Should we aim for a completely paperless office?
• Can we afford it? What hidden expenses will turn up?

These are all legitimate concerns. However, the answers to most of these questions depend on the EMR system you select and how you integrate it into your practice. If you go about it in the right way, you should avoid most or all of these problems.

In this article, I'd like to offer some advice on purchasing an EMR system and suggest some strategies that will help you successfully implement it in your practice.

PHOTOGRAPHY: PAT SIMIONE DIGITAL IMAGERY: JOHN BRUSZEWSKI

Choosing your EMR system

The most significant issue is choosing the right system. When comparing systems, try using the following strategies:

Check out your options at one of the national association meetings. This is a great way to sample most of the systems that are available before getting too involved with a salesperson. You can try out the basic system capabilities, get questions answered and compare features.

Once you've narrowed the field down to a few possibilities, ask for demo disks to try on your computer. Eventually, you can invite a manufacturer to bring his system to your office for a demonstration. (Everyone in your practice who'll be using the system should participate.) Allow at least a couple of hours for this process.

Ask about interfacing and customization capabilities. Issues to discuss might include:

• whether you're striving to eliminate all paper records, or just take advantage of system capabilities (such as optimizing documentation or minimizing transcription costs)
• interacting with satellite offices
• incorporating voice recognition
• interfacing with specific equipment
• cost concerns.

If the system seems like a promising possibility, let the company make a proposal.

Meanwhile, try to locate another practice (preferably not a competitor) that's already using the system you're favoring. Talk to members of that practice and find out what kind of problems they've had with the system (if any) and in which ways it's benefited their practice.

Make sure that adequate ophthalmic information is built into the system. Run through several patient scenarios that you commonly encounter in your practice. For example, check motility screens and see how the program deals with gonioscopy or extended ophthalmoscopy. Also, check out the system vocabulary. If you use terms such as drusen, subretinal hemorrhage, CSME or juxtafoveal CNVM, these should be part of the available terminology.

Shop for speed. Make sure the software allows for fast, efficient data entry. For example, the data entry time for a patient presenting for a 4-month glaucoma follow-up examination should be less than a minute. The system should also generate automated letters and prescriptions quickly.

Factors that can contribute to maximizing speed include:

• increasing the amount of memory in the system
• optimizing customization to fit your individual needs
• faster processors.

Gauge the learning curve. The system should feel intuitive to you and your staff. The last thing you need is a system that requires extensive learning and behavioral adaptation.

Consider customization issues. Take two or three average patients and run hypothetical exams through the system to see how well it performs. You'll want to determine:

• How much customization will the system require?
• How easy will the system be to customize?
• Who will do the customization: you, or the manufacturer?

The difficulty of customization depends on your needs, the product and the company you're dealing with. For example, if the interface uses listboxes, going into them to change the phrases or modifiers that are available should be easy for a doctor or technician to do. On the other hand, if a system doesn't have adequate drawing capabilities, the customization process could be far more difficult. In this case, you'd need to talk to the manufacturer and find out whether the company will make the changes you need -- and how much it will cost.

Look for ongoing support. When the system has a problem or needs servicing, will the manufacturer be there?

Check coding capabilities. Look for three things:

• Is the system compliant with current E/M guidelines?
• Can it be updated easily in the future?
• Does the manufacturer provide updates?

Consider interface compatibility. Ideally, you should purchase a system with "open architecture." This means that the computer system is compliant with common industry standards and the data is stored in a publicly available format.

Find out whether the EMR system you like will interface with the systems and instruments you currently use. Also, investigate how difficult it would be to transfer your records to a different system, should the need arise.

Evaluate security. The confidentiality of your relationship with your patient depends on a secure records system. Find out what the EMR system offers in terms of password protection, electronic signatures and other security devices. The Health and Human Services Guidelines require that an electronic signature have the following features:

• Message integrity. This ensures that the message cannot be altered between the sender and the intended recipient.
• Non-repudiation of the identity of the signer/user authentication. This provides strong, substantial evidence of the identity of the signer, to prevent a sender from denying that he or she originated and sent the message.

Evaluate data protection. Any time you're dealing with a computer, you should have data backup and redundant storage.

Consider the total cost. Primarily, you want to avoid being surprised somewhere down the line by unexpected "add-on" costs. (See "Cost-Related Factors".)

Making the transition

Switching to an EMR system can involve changing your work habits, learning new technology, customization, checking the effectiveness and performance of the new system and inputting data from previous records. For all these reasons, you'll need to make some decisions before you begin.

Should you plan to eliminate paper records? Even if your goal is a paperless office, you may want to keep paper charts along with the electronic records for at least the first 6 months, to minimize the stress of making the change.

Actually, many practices prefer to keep some paper records even after the EMR system is in place. For example, you might choose to keep originals of CT/MRI scan reports and lab results (after making limited data entry of relevant positives and negatives into the EMR), as well as referral letters, thank you cards and Christmas cards. If you don't have a digital imaging system, you might also want to keep the originals of color photographs or fluorescein angiograms, with entries in the EMR system summarizing their interpretation. Scanning a few representative frames might also make sense.

Keep in mind that a paperless office may not be necessary to achieve your goals, and trying to completely eliminate paper may end up causing you extra work.

Who should use the system first? The answer depends on your practice's specific needs, but in my experience it's easier to have your most highly motivated and computer-savvy physicians and technicians use the new system first. This will give you time to decide how much customization will be required and evaluate the system's performance.

How will you manage pre-existing data? Different practices use different approaches to this problem:

• scanning the paper chart pages into the system (this may use up an enormous amount of disc space)
• exhaustive data entry of pre-existing records
• entering selected data from the old records. For example, to summarize a glaucoma patient chart you could enter the diagnosis, type of glaucoma, allergies, pretreatment maximum IOPs, target IOP, prior ocular procedures, medications the patient hasn't tolerated or has failed to respond to, current glaucoma medications, degree of cupping, and visual field findings. This can be a cost- and time-efficient approach.

You should also decide whether you prefer to enter all pre-existing data en masse, or enter each pre-existing file as patients come in for their exams.

How will new data be handled? Decide how staff will preserve relevant information from phone conversations, lab results, pathology reports, CT/MRI reports, referral letters, or addendums to the exam information. Options include:

• scanning
• complete or partial data entry
• keeping originals in a paper file with relevant data entry.

Making the right choice

Electronic medical recordkeeping isn't necessarily right for every practice. If the system you currently use works well, you may not have a compelling reason to change. (And you can always switch to EMR at some point in the future.)

If you decide to switch, be sure to take all the issues I've outlined above into consideration. If you do, you should end up with a good electronic records system and minimal disruption during the changeover.

Welcome to the 21st Century!

U. Fusun Cardakli is a practicing ophthalmologist with Altoona Ophthalmology Associates. She is co-founder of Penn Medical Informatics Systems, Inc., manufacturers of EyeDoc, an EMR program for ophthalmologists.