GETTING INTO IT
Information technology has been a big asset in other industries. Can health care be next?
BY ROCHELLE NATALONI

Electronic information systems have transformed many industries by improving quality and productivity and lowering costs. But contrary to predictions, information systems have yet to make that impact ­ except anecdotally ­ in health care. Granted there are thousands of medical practices and hundreds of ophthalmology practices outfitted to the nines with either PCs, PDAs, PC tablets ­ or all ­ for paper-free electronic health records (EHR) management, as well as practice management applications. However, while ophthalmologists and their IT staffers interviewed for this article are eager to spread the word about how these tools are helping them optimize their resources, the majority of practices remain committed to traditional methods.

As Richard Hillestad, a RAND management scientist sees it, "Though physicians use the latest 21st century medical technology in their practices, most still use 19th century technology to store and retrieve information about their patients' health conditions, relying on paper medical records that aren't easily accessed or shared."

The biggest obstacles keeping private practices from embracing electronic health records are funding and physician support, according to a survey by the Medical Records Institute. In the survey of 576 healthcare organizations, lack of adequate funding or resources, lack of support by medical staff, inability to find electronic medical records (EMR) systems or components at an affordable price and difficulty creating a migration plan from paper to electronic records were some of the leading barriers to implementation.

For a global look at why information technology may be the best path toward increasing productivity and cost-effectiveness, complying with government regulations, enhancing quality of care, and satisfying the needs of an evermore savvy patient base, see "IT Will Save You," in the April issue of Ophthalmology Management.

The Pace Quickens

While actual EHR systems remain elusive throughout most of health care, talk about them is pervasive, and one of the factors that's driving this interest is HIPAA-mandated documentation requirements. Scott Riedel, marketing director for EMR developer MediNotes Corporation, says business has skyrocketed in the past 12 months in part because of HIPAA's regulations regarding security of patient information. "It's very complicated to secure paper in a busy practice environment, whereas with an EMR it's easy to see who input the patient information, and who's seen it and accessed it since then. All of the bits of data have an audit trail," he explained.

As part of a national effort to encourage the adoption of computer-based health records, the U.S. Department of Health and Human Services has signed a 5-year $32.4 million contract to license SNOMED CT, a clinical medical vocabulary owned by the College of American Pathologists, and at the behest of HHS the Institute of Medicine has developed a set of eight core functions that an EMR/EHR software system should perform. (See "Report Identifies EMR/EHR Core Capabilities") The core functions were selected based on their ability to improve patient safety, support effective care, assist in the management of chronic disease and improve efficiency. As further proof of EHR's buzz factor, RAND Health, an offshoot of the national think tank, recently embarked on a study to identify barriers to IT's widespread adoption in health care.

Interestingly, some IT insiders say that by the time those barriers are identified, they'll already be history. For instance, Jim Messier, vice president of ophthalmic products for healthcare IT software developer NextGen Healthcare Information Systems, says that while there is a 7% to 10% penetration rate of EMRs in ophthalmology practices today, he expects that to increase to 50% within 5 years.

"Early on, the industry had some big players make some big mistakes -- technology that failed or simply disappeared from the marketplace -- and because of that the overall mindset in the marketplace is one of hesitation and fear of investing into software applications and products," he said. One way around that, Messier says, would be if the American Academy of Ophthalmology (AAO) and the American Society of Cataract and Refractive Surgery (ASCRS) backed standards like SNOMED. "There's reluctance among the board members of these associations ­ some of whom were burned by earlier technology experiences -- to put their head out in front of the pack and say, 'here's a technology, here's what it can do for you, here are some case studies.' They need to go out into their own marketplace and dig for the good stories to show the potential of this technology," Messier said.

Plenty of ophthalmology practices have successfully transitioned from those earlier systems to others that are working well for them today and appear to be here for the long haul ­ NextGen, MediNotes, VitalWorks and PracticeXpert, Inc., to name a few. "I think at this point the vast majority of ophthalmologists know they have to get on board eventually. It's just a matter of getting beyond the fear and hesitancy inspired by what went down in the marketplace in the 90s and finding the right product," Messier said.

Are We on the Fast Track Yet?

Healthcare IT spending will grow at an annual rate of 7% until 2006, according to Gartner Inc., a Stamford, Conn.-based technology consulting firm. This slow but steady climb of about 2% per year reflects Messier's thesis that it's not if physicians will take the plunge, but when.

Veteran ophthalmic practice consultant John Pinto suggests that more ophthalmology practices haven't geared up already because there's no EMR that's quite there yet with respect to handling the unique needs of a busy practice.

"Look at the pace and the trajectory with which phacoemulsification was accepted within ophthalmology," he said. "Before too many years had passed, the vast majority of ophthalmologists had switched over from planned extracaps to phaco. This tells us that when something works well, ophthalmology is capable of diffusing that technology at a rapid clip, even against the uphill battle of new costs. By contrast, practices have been trying to go paperless for 20 years or more and we only see a scant handful that have implemented an EMR system," he said. "Without exception, for every system that I've seen in a real live practice -- and I see hundreds of practices -- the intent of the developer falls well short of the needs of the practice, and what ultimately happens is that either the system that's installed -- usually at great cost -- ends up being abandoned within a fairly short period of time, or it's incompletely implemented and we end up with practices that are maintaining paper plus electronic charts or selected doctors who throw their hands up and say 'forget about it, I'm going to stick with paper,' " Pinto said.

This scenario is exactly what Director of Information Systems, Jamie Steck, wanted to avoid in choosing an IT system for the Central Utah Multi-Specialty Clinic. "We wanted to have something the physicians would actually use," he said, "because if the doctors don't use it, nothing else matters."

The clinic implemented both a practice management system and an EMR within 90 days of each other. Steck investigated several EMR programs over a couple of years before making a selection. "TouchWorks from Allscripts Healthcare Solutions was a good EMR choice for us. It was a good implementation right out of the box; the interfaces worked well between TouchWorks and IDX Systems, our practice management system; it affords a modular approach, so we didn't have to implement the whole EMR at once, and we only had to pay for the modules we were using," he said. "Because we're an independent practice, the money to purchase the system came out of the physicians' pockets, so the cost factor was important."

Time and Money

"Physicians are most responsive to software that has a positive immediate impact on their revenue," says PracticeXpert, Inc.'s CEO Jonathan Doctor. "The system has to offer immediate cost savings and financial return, thus our focus on maximizing reimbursement through prompting for proper and thorough coding," he said. In designing the PXpert software, Doctor said, his developers kept in mind that physicians are most resistant to anything that disrupts their existing workflow. "At a minimum, the software has to be time neutral," he said.

VitalWorks is an IT hardware and software company whose products have been adopted by many ophthalmology practices. Its Intuition EMR can be installed, trained and fully utilized within a few days, according to Wendy McCuiston, Vice President of Internal Business Development. "Intuition EMR for Ophthalmology not only includes hundreds of pre-built and time-saving templates for the most common reasons for visit, but offers easy-to-use point and click mechanisms for charting critical clinical findings such as IOP, vital signs and more. The application not only provides a means for quickly documenting IOP, but also offers instant visual graphing of a patients' IOP over time," she said. "Medicine is an art, and no two physicians' have exactly the same approach, which can present its own problems with certain EMRs. Our intention is to allow the software to adjust to a physician's workflow," she added.

Return on Investment

While health care has not flocked to information technology as quickly as some other industries, forward-thinking physicians are realizing their return on investment with savings in salaries, space and time, according to Pat Wise, EMR director at the Healthcare Information and Management Systems Society. "Every year HIMSS presents the Davies Award to a healthcare organization or practice that exhibits excellence in the implementation of EMR. As part of their prize-winning application, they tell us how they were able to reduce staff because they no longer have to create charts and files or track down lost charts or lab records," Wise explained.

Connecticut ophthalmologist David Silverstone, M.D., was an early adopter of IT. He used Alcon's now defunct IVY System for 11 years, and now relies on NextGen. "We were able to easily transfer our IVY data to the NextGen System. The investment was high, but we've absolutely seen savings in terms of staff," he said. "Best of all, we never have a problem finding charts; I can log on to the computer from my home and pull up a patient's chart."

Dr. Silverstone went with NextGen after an exhaustive search. "Coming from a system that had been working well for us, our expectations and demands were high. There were a few other systems besides NextGen that we considered, but they've since gone belly up. That's why it's so important to consider the financial stability of the vendor before making a choice," he said. Dr. Silverstone uses both wired PCs and wireless portable handheld devices that are similar to tablet PCs. "We take them from exam room to exam room and never have to turn our backs on the patients when putting information into their record," he said.

The Shepherd Eye Center in Las Vegas is another early adopter, and it too started out with Alcon's IVY System. Since starting with that system and one physician, the center has grown to seven physicians and moved on to the NextGen system including practice management, electronic medical record and optical inventory software. All incoming paper is scanned into the EMR system and shredded within a week. "We've been recording data real-time in exam lanes since 1987," said Kim Heikkinen, Shepherd's information systems manager. "People often overlook a simple but really important benefit of the EMR, and that is the ability to pull up a patient's chart from anywhere in any one of the offices and answer a patient's question. Everyone who requires access to that record can quickly have access," she said.

Since implementation, the practice has reduced the business and medical records department staff by five, for an estimated yearly savings of $150,000. Planned implementation of diagnostic equipment interfaces are expected to reduce clinical staff by at least one more person. "Though it is difficult to project if we can reduce staff further, EPM Worklog, Optical Inventory software improvements and faxing of referral letters and medication prescriptions will further improve productivity of existing staff," Heikkinen said. Another perk is that the practice's capture rate has increased. "We print spectacle prescriptions directly from the exam lane in our optical department. Obviously patients have the option to go elsewhere, but since we started that, our retention rate increased by 5%," she said.

Steck, of Central Utah Multi-Specialty Clinic, conducted a year-long, soon-to-be published study of the costs and benefits of implementing the clinic's EMR. "Our first-year calculation for EMR savings was $952,000; and our five-year [estimation] is $8,200,000," he said.

The practice has reallocated staff to current needs. "For example, we had estimated that we would reduce the number of FTE's in our chart room by 20% in the second year. Due to efficiencies in the chart room, and through attrition, we have seen that reduction already in the first year, and have not rehired any after they decided to leave," he said. "Nurses' time in filing and finding charts has greatly been reduced. We are asking them to perform other duties relating to the EMR, but patient care is what they were trained to do. Right now we need more EMR support staff, but due to efficiencies we are seeing significant reductions in the records room," he added.

In many instances, less paperwork means more employees can be used to provide direct patient care, as in the case of the Eye Care & Surgery Center of New Jersey, a three-site, five-physician practice that is completely paperless since implementing Charting Plus, an EMR by MediNotes. The practice sees 3,500 new patients a year, and logs 20,000 patient visits annually. It has increased sales of optical products by 25% since adding eyeglass prescription printers, and is eyeing the possibility of e-prescribing now that a recent ruling made that legal in New Jersey.

"We started out with a system that was not robust enough to handle our database. Then we transitioned to MediNotes about three years ago," said practice owner Ivan Jacobs, M.D. "It's been a tough trip, but it certainly has been worth it. We're saving around $125,000 a year just in personnel without even cutting back on staff." The practice no longer uses scribes, so the former scribes are now employed as technicians. "Now we can see more patients."