Using EMR to Improve Patient Care
How one practice improves outcomes through creative use of EMR.
BY MARK ROSENBERG

Currently, fewer than 20% of ophthalmology practices in the United States employ electronic medical records (EMR) in their daily practice. The transition from paper charting to a paperless office is a challenging and expensive endeavor for ophthalmology practices large and small. This article will share with readers how converting to EMR has greatly improved the quality of care for patients of the Barnet Dulaney Perkins Eye Center, a multi-site practice in Arizona for which I serve as the executive director.

The decision to convert to EMR is often painstaking and cumbersome. Over the past two decades, three ophthalmology-specific EMR packages were introduced only to be withdrawn several years thereafter because the vendors could not justify the cost of supporting the platform and the need for perpetual updates. The transient nature of these early ventures into EMR made ophthalmologists guarded about venturing back into the paperless office.

Despite these fears, the federal government and third-party payers have made it abundantly clear that all healthcare providers should adopt EMR platforms over the next decade if they want to be able generate the data that will allow them to continue be eligible to participate in Medicare and just-over-the-horizon programs such as pay-for-performance. The past decade has been punctuated with questions such as "should we" venture into EMR. The coming decade will be defined with questions such as "which vendor" and "what technology" should we adopt.

The federal government now appears to be focused on generating outcomes data so as to determine who will and who will not be paid, and at what level. In advance of government mandates, The Barnet Dulaney Perkins Eye Center ventured into the world of EMR several years ago. The learning curve for implementing a fully operational EMR system is quite steep. The probability of glitches and unexpected obstacles is great at the onset of EMR deployment. However, with the help of our doctors, staff and a resourceful information technology (IT) department, we have been able to improve the level of care within our practice on two major fronts.

Complete and Accurate Charting

The Barnet Dulaney Perkins practice is using EMR to optimize LASIK treatment plans and has been successful in reducing its retreatment rate.

Our practice consists of more than 15 independent offices spread throughout the state of Arizona. Patients are often seen at multiple locations during their course of treatment. Prior to EMR, we had to physically have the patient's chart transferred from location to location in advance of the patient's visit to a given site. When patients presented for emergency visits, we would often have to create a "temporary" chart by faxing several pages of the most recent chart notes. For patients who had been within our system for many years, it was often impossible to fax over the entire chart, which often exceeded 50 pages. Many patients were seen in our metropolitan Phoenix office during the winter months and in our rural northern Arizona office during the summer months. Over the course of several years, these patients inadvertently evolved into having two unique charts, both of which were a montage of original chart notes as well as faxed notes. In essence, these patients had two distinct charts, neither of which was truly the original.

The first manner in which EMR helped improve the level of patient care was that it helped eliminate the need for temporary charts which were not necessarily truly representative of all of their office visits. EMR allowed patients to be seen at any of our statewide offices without having to worry if their chart was going to be at the correct office at the time of their visit. Multiple doctors who were geographically separate could participate in a patient's care without having to create duplicate charts. Additionally, much like the Bermuda Triangle where many ships and planes have been inexplicably lost, medical charts have been known to "disappear" when they are removed from their office or origin. EMR has eliminated this Bermuda Triangle phenomenon completely.

Fewer Refractive Enhancements

Perhaps the most impressive benefit of EMR was demonstrated within our refractive department. The implementation of EMR allowed our surgeons to define and refine surgical nomograms for refractive procedures. The ultimate benefit of refined algorithms was a significantly lower enhancement rate for all refractive procedures among all of our surgeons.

In less than 2 years following the implementation of EMR, our LASIK enhancement rate dropped from nearly 20% to under 3%. Our refractive surgeons perform in excess of 5,000 refractive procedures annually. Prior to EMR, it was difficult to retrospectively evaluate how closely the outcome of a given procedure matched the surgeon's expected outcome.

It has long been understood that nomograms are a vital component of successful refractive surgery. EMR mandated that preoperative, perioperative, and postoperative data be input to the relational database with very exacting standards. A robust EMR system mandates that the data be input in a uniform and accurate manner. Once the data has been captured, it is merely a matter of applying statistical models to assess both subjective and objective outcomes. The statistical models allow for the generation of precise yet dynamic surgical nomograms. The nomograms continue to evolve to even more exacting standards as the data set grows. The ultimate benefit of EMR in this example is improved surgical results from the initial procedure, as well as a significant decrease in the enhancement rate.

It is our belief that the benefit of EMR as a relational database can be extended beyond corneal refractive surgery. There is great promise in other areas, as we have already begun to apply EMR to help us understand more about the evolving field of accommodative and multifocal IOL implantation. The utilization of these IOLs is in its infancy. The potential of this technology to correct presbyopia appears to be great. The ability to realize that potential is integrally related to our ability to assess all subjective and objective parameters which factor into our accommodative abilities. We believe that within our practice, our EMR system will be a critical component of achieving successful surgical outcomes with this evolving technology.

Drilling Down for Data

Another quantum improvement in patient care evolved out of our integrating our EMR database with our electronic practice management system, sometimes known as EPM. This integration allows us to follow an infinite number of cohort groups in a prospective manner.

We have developed a reporting mechanism that identifies a cohort group (for example, all LASIK patients whose original procedure was in October 2004, performed by surgeon X using laser Y) and track subsequent events such as need for enhancement, overcorrection, undercorrection or development of complications such as diffuse lamellar keratopathy (DLK). We can "drill-down" into the data to look to see if occurrences such as DLK occur more commonly during a given time of year, with a given laser, or in the hands of a given surgeon. The ability of our NextGen system (EPM and EMR) to study the data in these varied capacities will clearly lead to great insight that would otherwise never come to light. The ultimate result of this insight is improved quality of patient care.

An important medical-legal benefit of EMR within our practice has been our improved ability to track patient compliance on many levels. Our EMR system allows us to determine fairly accurately how patients are using their medications. Additionally, we can study the prevalence of specific side-effects with a given medication.

Our EPM component allows us to assess whether a given patient fails to present for a given appointment or series of appointments. This is especially important because the legal burden of failure of a patient to follow-up in the office rests with the treating physician more than with the negligent patient. Failure to identify a patient who does not return for follow-up can leave the physician liable for failing to maintain a therapeutic relationship between the physician and the patient. Again, our implementation of EMR has yielded significant improvement in patient care by allowing us to better track patient compliance at all levels. The relational database inherent in our system allows us to know which patients are being seen routinely and which patients need to be tracked to prevent them from falling through the cracks.

Tele-Medicine for Glaucoma

Finally, the implementation of EMR has improved the standard of care for patients with glaucoma within the Barnet Dulaney Eye Center network. As I have shared, our practice includes more than 15 offices which span the state of Arizona. Patients who live in rural areas have historically had to come to the city to receive the highest level of subspecialty care. Many of our rural satellite offices are staffed by general ophthalmologists and medial optometrists. Despite the fact that both of these types of doctors can treat glaucoma, the highest level of care can be delivered by a trained subspecialist. An EMR system which allows all chart notes and images to be viewed on any networked computer enables us to practice true "tele-medicine." Specifically, our glaucoma specialist, Andrew Rabinowitz, M.D., has the ability to review cases remotely from where the care is delivered. Thus, although all of our glaucoma patients do not necessarily "see" a glaucoma specialist, our glaucoma specialist can see the patient in a virtual manner. In this manner, we can standardize the level of care which all of our glaucoma patients receive.

There is no substitute for face-to-face contact between the doctor and the patient. However, when this type of encounter is geographically improbable, virtual chart assessment may be the next best thing. Our practice follows more patients who are at risk for or who actually suffer from glaucoma than any practice in the state. More importantly, with the implementation of EMR, these patients will be afforded the opportunity to be evaluated and treated by a fellowship trained glaucoma subspecialist.

Affording all of our patients the opportunity to receive care from a subspecialist is an occurrence which can only be made possible with an EMR system.

Overall Benefits

EMR has provided many improvements to patient care within our practice. These benefits include but are not limited to:

► providing subspecialist care to patients who live far from metropolitan areas

► improved ability to ensure all aspects of patient compliance

► improved integration of clinical data with billing and scheduling

► improved surgical outcomes for refractive surgical procedures

► refined surgical nomograms specific to surgeons, lasers and sites

► significantly lower surgical enhancement rates for refractive procedures.

The era of electronic medical records is only beginning. I believe that early adopters will achieve benefits of many fronts. These benefits are far reaching, and ultimately serve to dramatically improve the level of patient care at our facilities. OM

Mark Rosenberg has served as executive director of the Barnet Dulaney Perkins Eye Center, headquartered in Phoenix, Ariz., for the past 12 years.

More Ideas for Improving Care
By Jerry Helzner, Senior Editor

William H. Constad, M.D., of Hudson Eye Physicians & Surgeons in Jersey City, N.J., finds EMR quite helpful in managing patients with chronic diseases and conditions.

"Having an EMR system makes it easy to track tests, medications and changes of medications," says Dr. Constad. "Not only does the patient benefit, but the practice increases the return on its EMR investment by eliminating the wasted time previously used to search for misplaced paper records."

Dr. Constad asserts that it is important that diagnostic instruments be integrated into the EMR system, allowing test data to be automatically transferred into the patient record. He notes that having the capability to enter data automatically eliminates mistakes that result from a staff member misreading a test result and entering the wrong number, or from a doctor trying to interpret indecipherable handwriting. These mistakes can lead to errors in formulating a patient's treatment plan, with the result being poorer outcomes.

David B. Glasser, M.D., of Patapsco Eye in Columbia, Mo., says the practice uses its MediNotes EMR system in ways that were not possible, or were too unwieldy, with paper charts.

"We use the 'alerts' feature in Charting Plus as a tickler file to notify us when to check lab results, recall patients for tests and visits, and verify that they have obtained recommended follow-up with their primary care physicians or subspecialists," says Dr. Glasser. "There have been several instances where patients dropped the ball on follow-up. Our EMR reminded us to contact these patients and get them back on track.

"We have also set up a 'Glaucoma Monitor.' This allows us to look at trends in our patients' IOP readings, the medications they are on, and tell at a glance when their last visual field test, gonioscopy, pachymetry and nerve fiber layer analysis was done, as well as see the results of all of these tests," he notes.

Peter J. Polack, M.D. of Ocala Eye in Ocala, Fla., cites the "big picture" benefits of EMR in improving patient care. He says that the information an EMR system can provide enables physicians to accurately track a patient's course of treatment, detect adverse reactions between medications and alert a physician if a patient has a serious allergy.