EMR: Wider Adoption is Expected
Improving systems should drive demand.
BY SUSAN JONES

ILLUSTRATION: MARK HEINE

How close is the ophthalmology community to widespread adoption of electronic medical records (EMR)? Courses, articles and even whole conferences are dedicated to explaining their advantages. Many practices have taken the plunge into EMR and say they would never give it up. Even the President of the United States wants doctors to implement these systems. But some have jumped in unprepared and undertrained, or with the wrong system, and then gone back to paper records. What will it take for EMR to catch on throughout the ophthalmology community? Are physicians still waiting for a standard? We'll explore those questions and provide specific answers in this article.

EMR Gets This Vote

Talk to the vendors of EMR systems -- as we did -- and you find that almost all of them agree that no more than 10% of ophthalmologists currently use electronic medical records. Many vendors believe the percentage of EMR users is still under 7%.

One of the ophthalmologists who currently uses EMR is Dwayne B. Baharozian, M.D., founder and president of The Family Eye Care Center in Westford, Mass., who implemented Compulink's system. He says that he's highly satisfied with the results he's experienced.

Dr. Baharozian reports that although costs such as hardware, software, installation and maintenance are a concern, they shouldn't be the most important considerations in adopting EMR. He says that the key factors in implementing EMR should be the overall performance of the system, its reliability, and customer support.

From the outset, Dr. Baharozian wanted the following elements in his EMR system:

► customizable, easy-to-use software in order to suit his way of documentation

► an all-inclusive software package including EMR, electronic scheduling, optical sales and medical billing

► a system that could interface with various pieces of diagnostic equipment -- although not all types of equipment are capable of interfacing with EMR

► superior technical support/customer service from a company with a proven track record.

He was able to obtain all the features that he wanted.

"By researching the various products available prior to purchasing a system, then choosing a system which addresses your office's specific needs, the initial costs are easily justified," asserts Dr. Baharozian. "EMR has unquestionably given my practice an outstanding return on investment (ROI)." A few examples of how EMR improved the practice's ROI include:

Elimination of paper charts. With traditional paper charts, a staff member needs to pull a chart, insert a new exam sheet, and then file the chart once the patient visit is completed. At a typical, single-physician practice, this could occur 40 to 50 times per day. Dr. Baharozian calculates a savings of at least 2 staff hours per day by not having to do this. "Furthermore, there is no such thing as a lost chart," he notes.

Integration of computerized refraction. Dr. Baharozian says interfacing a computerized refracting system with EMR has made a major step in an eye exam standardized, as well as more efficient.

"I estimate that 2 to 5 minutes is saved per patient while yielding a highly accurate and reproducible refraction/eyeglass prescription," he says. "Once the refraction is completed, the data is seamlessly downloaded into EMR with the simple push of a button."

Simultaneously, an eyeglass prescription is printed out to the optical shop. Every patient must then visit the optical shop to obtain the eyeglass prescription. During this process, each patient meets an optician who discusses his or her eyeglass needs.

"This encounter greatly enhances the chance that a patient will buy a pair of glasses if they are needed," says Dr. Baharozian. "Our capture rate is 85%."

Computerization creates a competitive edge. "The computerization of the office has distinguished my practice from others," says Dr. Baharozian. "Patients are impressed with the technology and this generates many word-of-mouth referrals."

Overcoming Fear of Change

Although EMR has helped Dr. Baharozian create significant benefits for his practice, he initially had a huge fear of making the change. He thinks it may be the number-one reason ophthalmologists hesitate when considering converting to EMR.

Most doctors are comfortable with tried and true methods, he explains. Going to EMR represents a significant paradigm shift. First, you must understand the benefits, then embrace the concept so that all others within the practice will follow your lead. If a doctor or any higher-level manager isn't ready and willing to accept the challenge, then the remainder of the office staff will be less likely to accept the conversion.

"I personally overcame the fear because I realized there were significant benefits once I got past the learning curve," says Dr. Baharozian. "The final push came once I realized I was running out of space for paper charts. This made the decision easy for me."

Dr. Baharozian found that, overall, his EMR neither slowed down his exams nor sped them up.

"However, an enormous advantage is that EMR is always legible and accessible," he notes. "In addition, when done properly, EMR is far more compliant with Medicare and insurance company charting requirements."

But Others Wait

The Dr. Baharozians of the world are still in the minority, though. Daniel R. Whipple, M.D. of Avon, Ind., and Raleigh Ophthalmology of Raleigh, N.C., are representative of the majority of ophthalmology practices.

Neither of these practices is necessarily waiting for a standard system that everyone can use. Dr. Whipple says he wants something that will help his practice to be more efficient, and allow him and his staff to do their jobs better. He thinks the biggest advantage an EMR system provides is a way to document more thoroughly and efficiently. Liz Parrott, administrator for Raleigh Ophthalmology, says her practice is waiting for stability in the EMR marketplace.

Parrott wants to be "blown away" when she looks at the exam templates in an EMR. She wants to see everything on one page, have a minimum number of keystrokes for entering data, and have the system flow logically. Also, she wants a system to be reasonably priced, to be easy to use, to work with equipment, and to allow doctors to do drawings. She expects an EMR to be as efficient to use as paper.

Hardware and software costs aren't major obstacles for either Parrott or Dr. Whipple. Parrott personally believes EMR will produce a sufficient ROI. However, trying to get the doctors in the practice to believe that they'll see a good ROI is another thing.

She cites an example of one of their providers needing to access an eyeglass prescription over the weekend, but not having the time to drive across town to retrieve it.

"With EMR, we would have had access to the record," says Parrott. "That's a tangible benefit."

She also sees eliminating the need for staff members to look for lost charts as a cost-saving benefit, but notes that this type of clerical savings may not affect the doctors in a way in which they can see a direct benefit.

"EMR is more than just documenting patient charts," says Parrott. "It also includes all of the behind-the-scenes benefits such as being able to fax prescriptions directly from the EMR, automatically generating custom referral letters based on exam information, and saving countless employee hours by not having to search for charts."

Doctors Drag their Feet

Like others, Parrott sees physicians' fear of change as the biggest obstacle to EMR adoption. She notes that changing practice management systems wasn't a particularly big issue for the doctors because they didn't have to deal with it directly. She contends that with EMR, doctors may fear they'll be less efficient and not see as many patients. Also, she believes that older doctors aren't as computer-savvy as their younger colleagues, and may be more reluctant to make a big investment in computers in general.

Dr. Whipple agrees that reluctance to change and fear of being slowed down do exist in the ophthalmology community.

"The key is user friendliness," he says.

Dr. Whipple says he wants a very easy way to document the chief complaint, the history of present illness, physician's impression, the treatment plan, and the patient education materials each patient has seen. He believes the rest of the record is more easily documented than these key elements, and likes the fact EMR systems allow findings to be pulled forward from previous exams.

Dr. Whipple also wants a customizable layout so that he can print a hard copy the way he wants it to look. He notes that most ophthalmologists currently have exam sheets and scribes to whom they dictate out loud. These physicians know where to look on their exam sheet for all the exam details. He wants a summary printout that looks like his exam sheet -- not in paragraph form. He believes doctors are picky about the layout of their exam sheets.

Additionally, Dr. Whipple would like his EMR system to have coding reminders, so that if his staff attempts to bill codes beyond what they have documented, the software would warn them they didn't have enough documentation. He understands that coding involves subjectivity regarding medical complexity, but ideally, he believes a good EMR system should help doctors document and code better.

But Dr. Whipple says he hasn't yet seen any EMR systems that are worth the cost from both "a dollar and a hassle standpoint," with the hassle part being the conversion and training.

Vendors Face Challenges

The issues raised by Parrott and Dr. Whipple have always presented challenges for both EMR vendors and ophthalmic practices. In response, EMR vendors have been listening to physicians and practice administrators, which has led to the development of EMR systems that do just what these practices have requested.

With the systems constantly improving, the lack of greater market acceptance of EMR might just come down to a reluctance to change. But if ophthalmologists want the benefits of a paperless office, improved documentation, more accurate coding, and easy access to records from home, hospital and vacation, they'll eventually have to make the decision to computerize.

Link Wilson, president of Compulink, notes: "Change is scary for most of them, and it's hard to break their old habits though there's no question the bottom line of the practice will benefit from increased efficiency."

Wilson says his company's biggest challenge is "educating our existing user base built over 20 years about the benefits of EMR and getting them to take the step." He finds new clients now ready to adopt his product because of its "drawing, imaging, documents, and equipment interfaces, and how that information is integrated into their entire business."

Wilson believes doctors want "a comprehensive EMR that is all set up for them to use out of the box but has the ability to be easily customized by allowing table and screen changes to fit their unique needs." He says they also want "a solid reliable solution that they can depend on day in and day out and that auto codes for them."

Wendy McCuiston, vice president of Clinical Operations at VitalWorks, finds that some practices are concerned that the transition to EMR will have a negative short-term impact on revenue and productivity while the new system is being learned.

"We tell potential clients that such concerns pale in comparison to the benefits they can receive from adopting a good, ophthalmology-specific EMR system such as the one we provide."

Some Vendors Overpromise

According to OmniMD CEO Divan Da've, another major challenge to reliable EMR vendors is that salespeople from competing vendors will overstate the benefits of adopting EMR. Such "hyping" can include touting the total elimination of paper in a practice, minimizing the amount of training required, and saying that practices will benefit immediately. Claims that sound too good to be true cause doctors to be skeptical, says Da've.

Da've notes that EMRs can capture information during exams using point-and-click data entry, which offers a tremendous leap in technology. But he also accepts the fact that some doctors aren't yet ready to adopt this technology.

"Doctors not in tune with PDAs and point-and-click find it difficult to adapt," Da've says. "If systems are cumbersome, they won't use them." Instead of touting "totally paperless" offices, he thinks a realistic goal is producing, using and storing less paper.

Jim Messier, vice president of Ophthalmic Products at NextGen, agrees that very few doctors ultimately think they'll be totally paperless.

Jonathan Doctor, CEO of PracticeXpert, Inc., thinks another big challenge for vendors is getting one system to "talk" to another. That means practice management systems, as well as computerized diagnostic equipment, "talking" to EMR systems.

Tracy Burns, sales manager of KeyMedical Software, Inc., believes that workflow is one of the major challenges for an ophthalmic EMR system. She says that having a system that's designed with your ophthalmology practice in mind is a must.

"You just can't have a 'toolbox' to help the practice design the EMR," says Burns. "It has to be ready to use, with all the workflow issues addressed, or the office will just simply not make the jump from paper to EMR."

Says Tim Beatty, support/sales representative with Penn Medical Informatics Systems, Inc., makers of EyeDoc EMR: "One of the main reasons EMR has been slow to catch on with most ophthalmic practices is that most EMR companies provide a program that was initially written for primary care physicians or other specialties. They're extending into ophthalmology by providing superficial interface customizations. However, the fundamental design of the program doesn't support efficient, quick ophthalmic data entry, such as extended ophthalmoscopy with its detailed picture.

"Practices that purchase some of these systems go through steep learning curves," Beatty continues. "This includes a tremendous amount of customization and financial investment. When some of these practices give up on these systems, it slows down the overall acceptance of EMR."

He goes on to note: "The challenge for the EMR industry is to come up with an intuitive ophthalmic EMR system specifically designed for the practicing ophthalmologist that's cost effective, user-friendly, and efficient. It needs to have rich ophthalmic database contexts, rich drawing capabilities and equipment interfaces."

Scott Riedel, director of marketing of MediNotes, says that "over the years, the biggest obstacle has been being patient and doing the right things so we were ready when the market opened up. The market is just starting to crack now and I think we've positioned ourselves well. The biggest challenge now is executing well everyday, making sure our developers are adding features that really matter, and that our training and support departments are benefiting our clients."

What Do Practices Want?

MediNotes' Riedel says he hears physicians saying they want to go paperless, see more patients, and still be able to have more time for themselves. Reidel says one doctor on a MediNotes system previously had 3 hours of charting at the end of each day, but now has only 15 minutes. Reidel says practices have reported a ROI in 1 to 2 years by eliminating transcription and reducing the number of administrative staff.

Burns has found that physicians using her company's system are adding more patients to their day without having to hire additional staff members. They're also able to do more with less space by eliminating the need for record storage.

Da've of OmniMD sees three very important requirements doctors should look for in an EMR system:

► The system should make the whole workflow electronic so that nurses and technicians start the entry of the medical record electronically.

► The system must aid physicians in legally complying with ICD and CPT rules.

► The system must help a practice be more profitable.

Jerry Shultz, vice president of sales and marketing at NextGen, hears doctors say they want stress-free, low-cost EMR implementation. He says they don't want to be slowed down, look foolish while learning the system, or alter the way they see patients. He says they want the EMR system to protect them medically/legally and help them improve the quality of care by allowing access from home for the on-call doctor.

Messier of NextGen says the only way to grow practices without adding staff is with EMR. He notes that HIPAA regulations have pushed the acceptance of EMR and elimination of paper charts for privacy and legibility reasons.

Who Can You Count On?

One fear Parrott has is that the vendor her practice eventually chooses won't be in business long. She wants a sense of security. She wants to deal with a company that will be around to support her system over the long haul.

Wilson of CompuLink says: "The consolidation of practice management and EMR vendors continues every year. Users want a completely integrated solution, and the complexity of all the options available continues to grow. Users no longer want a billing/scheduling solution, with a separate EMR solution and a separate inventory/dispensing solution, and a separate LASIK marketing product. They want it all integrated for maximum efficiency with fewer vendors to deal with to reduce issues and finger pointing."

Beatty of Penn Medical Informatics adds that companies that can meet ophthalmologists' needs and provide reliable, timely ongoing support to their clients will prosper regardless of their size."

When will large numbers of practices implement EMR systems?

Dr. Baharozian says he's "dumbstruck when I think about how little computers are utilized in a typical medical practice. Once a fair number of practices realize the benefits and convert to EMR, momentum will develop and EMR will become widespread. This will take roughly 5 to 10 years."

Parrott thinks large numbers of practices will implement EMR systems as soon as the doctors who are over 60 retire.

"It's the young doctors who are 'gung ho' about using EMR, she asserts. "Older ones don't want to make the change."

Messier anticipates large numbers will implement EMR when the ophthalmic societies endorse the concept. He predicts societies will eventually realize their members will be providing improved patient care by having better documentation available, and that medical organizations can do better outcomes analysis when their members use EMR.

"I think we're really close," Messier declares. "EMR activity is picking up. Within the next 1 to 2 years, there will be a huge growth. The market for EMR systems will double or triple."

"President Bush has been talking about EMR as the 'medicine' for the medical industry since January, so I think EMR now has some top-of-mind awareness," adds Reidel. "I would say that it will really build up at the end of this year, and about 50% of clinics will have an EMR by the end of 2006." McCuiston of VitalWorks agrees that an EMR penetration rate of 50% or more is possible "in the very near future." She's also a bit more optimistic than most other observers in estimating the number of ophthalmology practices currently using EMR.

"Doctors know they have to have EMR, thanks to Bush declaring prescriptions be electronic in 2007," notes Da've. "But doctors have to be realistic enough to be aware that EMR doesn't produce miracles."

The Future of EMR

Assuming EMR takes shape in a similar manner to practice management systems, there will never be a "standard" EMR. Practice management systems use the government- mandated ANSI X12 837 and 835 standards for electronic claims and remittance, but the appointment scheduling, billing, patient registration and reporting all vary from system to system.

With EMR, there is not yet a government-mandated or even recommended standard of any kind, though limited efforts toward this end are taking place. ASTM International, the Massachusetts Medical Society, and the Health Information Management and Systems Society are jointly working on a Continuity of Care Record (CCR). The purpose of this standard CCR is to provide at least a minimum level of quality and uniformity when patients' records are transferred from one provider to another.

The CCR is an extension of a Massachusetts Department of Public Health three-page paper-based Patient Care Referral Form, which has been in use in Massachusetts for several years. This CCR information is only a small portion of an EMR. (See C. Peter Waegemann. (2003). EHR vs CCR: What is the difference between the electronic health record and the continuity of care record? http://www.medrecinst.com/pages/libArticle.asp?id=42)

How the data is captured, displayed and stored will vary from system to system, driven by what doctors say they want and what developers can create.

Doctors and administrators say they aren't really waiting for a standard, so what's their next step?

Dr. Baharozian recommends that "anyone considering taking the EMR plunge should visit a practice utilizing the software package they're interested in buying. Also, the doctor(s) and staff need to be cognizant of the many start-up issues, which take time to resolve. The major question is, would I do it all over again, and the answer is an emphatic 'yes.' "

Susan Jones co-founded PRISM Data Systems in 1983, where she developed, implemented and supported practice management and EMR ophthalmic software solutions for more than 400 practices. She and David Jones co-authored How to Select and Implement the Right Computer Solution for Your Ophthalmic Practice. She can be reached via e-mail at susanjprism@yahoo.com.