Managing EMR Pressure
The increasing push toward electronic medical records can be unhealthy for your practice -- unless you take these steps.
BY SEAN MCKINNEY

Imagine if your new electronic medical records (EMR) disappeared after the computer crashed. Or if you had to pay nearly twice the cost of your new system for needed upgrades and support. Or, worse, if the needed upgrades and support weren't available.

These are but a few of the nightmares that can haunt a practice long after seemingly small but critical errors are made in the planning, purchase, and roll-out of an EMR system. You may be at high risk for these errors if, like most ophthalmologists, you've put off shopping for a system and are feeling an impulse to act as government mandates mount.

Just about every government official, from George Bush to Hillary Clinton, is pushing for a standard EMR system shared by doctors, hospitals, insurers, networks, and patients. The goal is to reduce medical errors, improve health care, and save money. Also, major insurers are planning pay-for-performance measures based on electronic records.

Another factor forcing doctors' hands is the April 25 compliance deadline for the Health Insurance Portability and Accountability Act of 1996 (HIPPA) Security Standards, many of which require software and hardware changes.

Currently, fewer than 10% of all doctors use EMR, most of them in large hospitals and medical centers. But that will change dramatically. Sales of EMR systems will skyrocket from $816 million in 2003 to $1.4 billion in 2008, according to the market research firm Forrester Research Inc.

Ophthalmology Management recently spoke with representatives from several practices who have implemented EMR. They offered this advice:

Don't stay stuck in the present. Like the computerized technology that advanced the diagnosis and treatment of eye disease by eons in the space of decades, the computerized technology now advancing record-keeping will become a key to practice success and quality patient care. As you would a new surgical technique, experts recommend that you make EMR the focus of your discussions with peers.

"I recommend that you talk to anybody who has adopted EMR," suggests Philip C. Borker, M.P.A., Chief Administrative Officer for The Eye Care & Surgery Center, a three-office multispecialty practice based in Westfield, N.J. "Get answers at medical meetings, through professional affiliations." Questions to ask:

• What would you do differently if you had to do it over?
• How much did your system cost and when will you recoup your cost?
• How many EMR vendors did you interview? (Get referrals)
• What was good and bad about the vendor you chose?
• How did you get everyone in your practice on board?

Don't take a piecemeal approach. Make sure you cover all of your needs. Although common threads run through EMR-equipped practices, no two are exactly alike.

"We started using EMR because it allowed our satellite offices to have copies of the records that weren't located at those sites," says Albert T. Milauskas, M.D., of Palm Springs, Calif.

Richard C. Edlow, O.D., chief operating officer of the Katzen Eye Group in Towson, M.D., says "the switch to the EMR system was wrapped around our decision 4 years ago to search for a new computer system that encompassed both an electronic practice management system and EMR."

Suzanne Bruno, M.B.A., C.O.E., executive director of Horizon Eye Care of Margate, N.J., says her practice adopted EMR to achieve chart compliance and to share data with six offices, nine physicians, and an ambulatory surgical center.

Ivan Jacobs, M.D., one of the owners of The Eye Care & Surgery Center of New Jersey, says he wanted fast and easy access to scans of fluorescein angiograms, operative reports, surgery consent forms, corneal topography findings, visual fields, and pathology reports.

Get your team on board. Assemble an effective planning team, including administrative, front desk, coding and billing, and clinical staff. Failing to heed input can result in resistance. "Changing the staff and physician mindset are the biggest challenges we faced," says Suzanne Bruno of Horizon Eye Care.

"You also need a strong IT-savvy project leader who can serve as liaison between the EMR vendor and the practice," says Borker of The Eye Care & Surgery Center. "This person needs to keep the project on schedule and on budget."

Your biggest challenge may be your peers. "To get doctors to give up pen and paper is hard," says Dr. Milauskas. "Don't even bother if you have a senior doctor who will resist this," says Borker. "Wait until he retires or find a way to work around his needs."

Borker's team allowed one doctor to continue to use a scribe because he didn't feel comfortable turning his back on patients to enter data. "There has to be flexibility all around," he says.

Enlist IT support. Perhaps the most vital member of your team will be an information technology professional, either an employee or a consultant. "Have a software and hardware person consult with you independent of the EMR vendor," says Dr. Milauskas.

"Issues relating to the hardware aspect of EMR are often overlooked and cause problems down the road," notes Borker.

The IT professional should recommend upgrades to meet current and future needs, such as new work stations, new personal computers, integration of multiple systems (including practice management and EMR software), wiring, T1 lines, data backup, designated servers, and interpretation of information from vendors.

Shop for vendors carefully. Ask potential vendors:

• How long have you been in business?
• What is your principal product?
• What language does your software use?
• How many installations have you done?
• What is your company structure?

"If you have a vice president of sales who's also a vice president of finance and technical support, that's not a good sign," says Borker.

Check references, asking for practices that fit your profile. Probe references for what challenges, big or small, they have faced.

Decide whether you want the EMR to link to digital instruments, practice management software, your optical dispensary, electronic claims submission software, or a drawing program. Ask what add-ons may be necessary or desirable, whether you'll be able to recommend future improvements to the vendor. Determine the availability and cost of 24-hour, 7-day-a-week technical support.

Before signing on with a vendor, "get all guarantees in writing," says Dr. Milauskas. "Protect yourself so they have to deliver."

"You can't accept anything the vendor says at face value," says Borker. "They are there to sell you a product and they tend to see issues through rose-colored glasses."

Ultimately, your system should be able to communicate across network lines with other providers, networks, and hospitals. At the request of the federal government, two nonprofit agencies, Health Level Seven (HL7) and Object Management Group (OMG), are hammering out standards envisioned for the entire industry by the end of 2005. Borker, who consults on the standards with a special ophthalmic workgroup, says today's reputable EMR companies are on target.

"Standardization is not going to be that hard, as long as it is done by industry and not government dictate," he says.

Don't go by your calculator. The cost of an EMR system can vary widely, depending on your needs and existing systems ­ ranging from $50,000 paid by the Milauskas Eye Institute to hundreds of thousands of dollars paid by The Katzen Eye Group. Bottom lines are only part of the equation, however. Consider cost-savings and revenue enhancements. For example, Dr. Jacobs saves $125,000 a year (not including benefits) on transcriptions and the salaries of five transcriptionists and $20,000 on paper charts. His accounts receivable are down, and sales in his dispensary have increased by 25%. Horizon Eye Care saves time and money in the dispensary by reducing regrinds. The Katzen Eye Group has reduced receivables by 50%, down to 25 days. Patient volume has increased by 30%. "I would strongly advise anyone to view the investment in terms of a 5-to-7-year amortization," says Dr. Edlow.

But don't be lured into extras you don't need. "There can be a lot of add-ons after the initial quote," warned Dr. Milauskas. "Get what you need. There are some very expensive systems that are not necessarily better than others."

Don't roll out too quickly. The Eye Care & Surgery Center timed its EMR launch during a slow season. A system of "feedback and correct" was used before the system went live. The practice operated on parallel systems ­ a paper charting system and an EMR ­ until the new EMR was up and running.

The Katzen Eye Group rolled out two doctors at a time, beginning with those who had the worst handwriting. Their schedules were reduced by 25% for the first week "and then they were off and running," says Dr. Edlow. Other doctors at Katzen used EMR only for new patients, or patients previously entered in the EMR database, before completely converting to EMR within a few weeks.

Katzen opened electronic records with old data the day before patient visits "to create continuity and eliminate much of the looking back and forth from paper to EMR," says Dr. Edlow. "It was also excellent clinical and EMR training for the staff."

Dr. Edlow recommends standardizing exam templates in detail, with input from technicians, doctors, and scribes. "Don't hesitate to place an extra computer station anywhere it might be convenient for technical staff access," he adds.

Horizon Eye Care team leaders first rolled out the most demanding subspecialty, retina, because it involved drawing requirements for compliant documentation. They then phased in new patients, followed by established patients.

Ready to Go Live?

As you contemplate your future in EMR, remember the benefits, including cost savings, staff reduction, improving quality control, and complying with regulations. By taking one step at a time ­ not a pressured leap ­ you should make a smooth transition.