Patient Loads and P4P Spur EMR Adoption

Today's systems better serve ophthalmologists.

BY RICHARD C. EDLOW, O.D. AND BRETT W. KATZEN, M.D., F.A.C.S.

Conditions for a "perfect storm" are gathering force within the ophthalmic industry. At the eye of this storm is growing pressure for practices to adopt electronic medical record (EMR) systems. Contributing influences include:

► The goal set by the federal government to computerize all medical records by 2014;

► The recent emergence of data-dependent pay-for-performance (P4P) initiatives among both private and public payers

► The anticipated growth of patients seeking ophthalmic services over the next few years.

For many ophthalmic thought leaders, the need for an EMR system is a foregone conclusion. They recognize that the technology is capable not only of assisting their practices in complying with governmental and payer-specific requirements, but can also help improve patient care, streamline internal workflow and facilitate growth.

While more and more ophthalmic practices are receptive to the idea of utilizing EMRs, this hasn't always been the case. The industry has had to clear a number of hurdles and recover from numerous setbacks to reach the level of readiness it displays today. In this article, we will discuss the factors that have affected EMR adoption by ophthalmologists and explain why the benefits from having an effective and efficient EMR system in your practice will continue to grow in the years to come.

Trends in EMR Adoption

The concept of electronic medical records was first introduced to U.S. healthcare in the 1970s. The idea gained ground slowly until 1991, when adoption accelerated as a result of an Institute of Medicare (IOM) report called, "The Computer-based Patient Record: An Essential Technology for Healthcare." The paper established a blueprint for implementing computerized patient records nationwide.

Like other medical specialists, eyecare providers began to investigate how best to incorporate EMRs into their clinical practice. Several vendors immediately brought systems customized for ophthalmology to market. Unfortunately, their success was short-lived. Because the systems were so specialized, they appealed only to an extremely limited industry niche and therefore were not profitable. The vendors, with limited internal resources, were unable to support the systems and abruptly discontinued their products.

This proved to be a significant blow to those in the ophthalmic industry who were proponents and early adopters of EMRs. They had invested considerable resources — not only in purchasing new technology, but in training staff and reconfiguring traditional workflow processes — and were left stranded with inadequate and unsupported technology. In essence, their investment was money down the drain.

Several large companies also entered the EMR market at that time but were likewise unable to effectively serve ophthalmic practices. Often, the EMR division was a small piece of the larger corporate structure, so it was not the focus of aggressive research or development efforts. The resulting EMRs did not meet the specific needs of medical specialties and offered little practical value to the user.

These disappointing vendor experiences reverberated throughout the ophthalmic community. Colleagues witnessed and heard about the failure of the initial EMR implementations, became highly skeptical about the value this technology could offer, and consequently lagged behind other medical specialties in adopting these systems.

This resistance has begun to dissipate in recent years, however. Product offerings have matured to better serve the ophthalmic industry. These companies concentrate exclusively on health information technology (HIT) like EMRs and practice management (PM) systems, but service a wide range of medical specialties. This has proven to be a perfect marriage of capabilities: a deep commitment to HIT, combined with adequate resources for ongoing product development and dependable product support. Programs like the Certification Commission for Healthcare Information Technology (CCHIT) also help ensure that EMR systems provide appropriate functionality.

Market Influences

Perceptions that an EMR was a "nice to have" technology were discarded at the turn of this century, when industry leaders began to realize it was truly a "need to have" tool.

Two specific events in the late 1990s inspired this paradigm shift. The first was the passage of the Health Insurance Portability and Accountability Act (HIPAA) in 1996, which encouraged widespread electronic data exchange in healthcare. The second was growing trepidation about the effects that Y2K might have on existing electronic systems. Both contributed to the realization that technology was a permanent and pervasive influence in today's world — and that ophthalmic practices needed to get on board or get left behind.

Since then, three converging trends have only accelerated and underscored the need for EMRs:

Increased Reliance on Diagnostic Technology

The ophthalmic industry has experienced rapid development of sophisticated diagnostic systems, relying upon technology to perform retinal scans, for instance, and to guide fluorescein injections. Best-of-class EMRs provide seamless interfaces with diagnostic systems like these and append digital images and results directly to the patient record. Likewise, they are able to import data-specific content such as automated refraction measurements, which the software can then analyze to generate trend reports.

EMR systems can also advance a physician's reliance upon technology to replace inefficient manual processes. Consider how often the physician must draw anatomical structures freehand, using specific symbols and colors to illustrate medical conditions — a horseshoe tear on the retina, for example. When the patient returns for a follow-up visit, the physician must replicate the previous drawing precisely and then indicate any changes in condition. With an EMR and tablet PC, however, the physician makes the drawing and saves it to the patient record. When the patient comes back, the ophthalmologist can simply cut and paste (or copy forward) the previous illustration and update it to reflect changes.

Governmental and Payer Influences

In mid-2004, President Bush announced an initiative to computerize all patient records within 10 years. His intent was to underscore a commitment for the development of a national health information infrastructure. To accomplish this, healthcare leaders were charged with dedicating resources to the creation of standards and to a secure infrastructure that would give clinicians access to vital patient information via a computer network. The foundational element of these evolving efforts is the EMR.

Concurrently, the emphasis on P4P and quality programs is increasing, and is expected only to gain momentum in coming years. Some industry experts predict that nearly one-third of physician pay will come from quality bonuses in the not-so-distant future. A range of industry forces have brought significant pressure to bear on practices, compelling them to implement new technology like EMR systems as a way to improve patient safety and quality of care, and to control spiraling healthcare costs.

Late in 2007, for instance, Health and Human Services (HHS) Secretary Mike Leavitt posted commentary on his blog about the rising costs of healthcare. He notes that the most viable solution is to base physician pay on how successful they are in keeping people healthy, rather than on volume of procedures they perform. He adds, "…we cannot make progress unless doctors adopt a system of electronic medical records," which allows the industry to gather quality data electronically.

Payers are sending the same message, loudly and clearly. During recent contract negotiations, United Healthcare required that a large Chicago-based health system, Advocate Health Care, adopt mandatory pay-for-performance standards, necessitating the systematic collection of performance and outcomes data. This approach, both partners agree, will necessitate collaboration on "several innovative programs designed to promote quality care and support the adoption of health information technology, including an ambulatory electronic health record…"

Best-of-class EMRs — particularly those that work hand-in-glove with PM systems — make it easy to extract required data points and compile them in formats compatible with P4P reporting requirements.

Growing Patient Base

Ophthalmic practices stand on the cusp of significant growth opportunities. The aging baby boomer population will increase the demand for a wide range of ophthalmic services. According to census figures, there were about 25 million individuals between 45 and 54 years of age in 1990. Estimates show that these figures are expected to grow to more than 44 million by 2010 before tapering off. During the same time frame, the Medicare population will have expanded from about 31 million (1990) to nearly 40 million (2010). This will continue to rise until it reaches nearly 54 million in 2020 — a total increase of 73% between 1990 and 2020 (U.S. Census Bureau, www.census.gov).

This growing and aging patient base will require increasing levels of ophthalmic care. According to figures compiled from generally reported levels of service, as well as usual and customary fees, it appears that the current market size is substantial, and will expand in relation to population shifts.

Age will not be the only factor contributing to market expansion. According to recent U.S. Census Bureau statistics, population increases among specific ethnic groups will also spur growth. African-Americans and Hispanics, for instance, are at greater risk for glaucoma and diabetic retinopathy than other populations. The need for eye care among these groups, of course, will also be amplified as they grow older as well and continue to represent a larger percentage of the overall U.S. population.

These projections will have tremendous impact on both the clinical and business side of an ophthalmic practice. EMR systems will help group practices respond and make the most of these opportunities. They will assist in capturing, aggregating and making accessible important information, which will improve care as patients are seen on a regular basis. EMR functionality likewise improves operational efficiency and productivity, which will allow eyecare practices to increase patient throughput, while controlling the costs associated with office space and support staff.

The View From the Trenches

Katzen Eye Group, Baltimore, Md., was among those practices heavily influenced by HIPAA and Y2K concerns. The practice began its search in 2000 and implemented an EMR from NextGen Healthcare Information Systems, Inc. (Horsham, Pa.) in 2003. Adoption paid off almost immediately. Katzen has increased patient volume and revenue by an average of 14% per year, in fact, without having to hire additional providers or support staff. The elimination of bulky paper medical records allowed the group to convert a file room into three additional lanes, and completely eliminate a file room in its new 25,000 square foot office. The practice saves $1,000 a month in paper and office supplies.

This success is largely attributable to the meticulous approach Katzen took throughout the EMR selection and implementation process. The group's doctors supported automation from the onset because it would allow them to focus on the practice of medicine, not endless paperwork or administrative duties. Leadership required that the selected EMR would need to offer ophthalmic-specific templates and mimic the workflow patterns of the practice to make the transition easier.

Katzen established two additional criteria: Leadership wanted an EMR with an integrated PM system to make optimal use of functionality — and of the data collected during office visits and procedures. Also, given the failure rate of ophthalmology EMR vendors in the past, the group sought a vendor that was financially stable and would devote significant resources to ongoing product development.

The transition itself was simplified by providing extensive training to select staff members, who served as on-site trainers and resources for their colleagues. Katzen also utilized the process of converting individual charts from paper to electronic formats in order to support training. Whenever a patient was seen, the scribe or ophthalmic technician summarized the last three "paper" visits into the electronic medical record. These "virtual visits" meant users became familiar with the technology more quickly, which drove adoption throughout the group. It also served to build patient EMR files without an investment in scanning or abstraction support.

The benefits that Katzen has realized continue to grow. At the top of the list is improved patient care. The EMR keeps comprehensive and up-to-date information at the doctor's fingertips during an encounter, and records can even be accessed remotely by staff members who are on call. Patient education is enhanced because staff can select and print specific materials to help explain conditions and treatments — like what to expect during and following multifocal intraocular lens implantation. The doctors are also able to generate reports to be sent to referring or primary care physicians, which not only improves long-term patient care, but solidifies a collegial partnership with these other providers.

Katzen's financial picture is also brighter. Coding support ensures that the appropriate E/M level is reported, based on documentation from the patient visit. Comprehensive charge capture is assured, since information for each encounter is automatically forwarded from the EMR to the PM system. Reworking and resubmitting denials is also achieved more quickly. In the past, billing staff would need to look at each denied claim and spend two to three days tracking down the information necessary to make a correction. Now, billers access the EMR and can resubmit claims in a matter of minutes. This dramatically improved cash flow. The ability to collect and extract data also puts Katzen in a position to participate in P4P initiatives when appropriate.

The availability of clinical and demographic data enables Katzen to optimize growth opportunities. Leadership can identify specific patient populations — those diagnosed with diabetes, for example — and proactively contact them about appointments for routine disease management. Likewise, it can develop marketing programs — for LASIK procedures, perhaps — and mail educational materials to appropriate candidates.

Finally, EMR implementation has served as a recruiting tool for attracting new ophthalmologists to the group. Most recent graduates from medical school are computer savvy and have relied upon technology throughout their education. They are predisposed to join a medical practice like Katzen that utilizes EMR and similar technology.

EMR: Its Time Has Come

There can be no doubt that the time for EMR adoption within the ophthalmic community has come. In addition to governmental and payer mandates, implementation of technology is being driven by intensifying market forces. Patients are increasingly "consumers" of patient care, and will select providers that offer the highest quality and best experience. Meanwhile, today's healthcare environment, along with changes in patient demographics, offers nearly unlimited opportunities for ophthalmic providers to expand and develop their practices.

Of course, there are still significant barriers to EMR adoption — cost of the systems, for instance, as well as natural human resistance to change. Nevertheless, it has become clear that those who lag behind the technology curve will find it difficult to survive, much less thrive. OM