EMR: Why Aren't Ophthalmologists Plugging In?

Our exclusive survey reveals the fears and frustrations that are holding this promising technology back.

First in a four-part series on overcoming obstacles to EMR adoption.

BY JACK PERSICO, EXECUTIVE EDITOR

The contrast is striking.

You'd be hard-pressed to find a medical office more high-tech than an ophthalmologist's. In the exam rooms, an array of sophisticated devices allow the doctor and staff to view, analyze and document every ocular structure from the adnexa back to the optic nerve with remarkable precision. But outside the exam lanes, more often than not, somewhere there's a massive wall of hard-copy patient records: thousands of manila folders, each containing a sheaf of hand-written notes, photocopied prescriptions, faxes, printouts and other miscellany that collectively document years or even decades of care.

Though computer-based solutions to medical record-keeping have been on offer for about 25 years, and there is no shortage of options in the marketplace to choose from at present, perhaps as few as one in 10 ophthalmic practices have adopted electronic medical records. Why would such technologically-inclined professionals prefer ink-on-paper data storage, with its attendant shortcomings of limited access, cumbersome storage and vulnerability to fire or flood? For many physicians, medical records fall into the “if it ain't broke, don't fix it” category, and that sentiment is doubly strong when the proposed solution comes with a hefty price tag.

To tease out the specific concerns that underlie such skepticism, we recently conducted a reader survey targeting those ophthalmologists who do not currently have EMR implemented in their practices and say they have concerns about how to do so. The results displayed here naturally reflect that mindset. EMR proponents surely exist in ophthalmology, but were excluded from this survey by design. And as our sample size of 102 respondents may be too small to yield statistically significant data, it's best to consider the findings more akin to an opinion poll.

And opinions on EMR, we found, were in abundance.

Fear and Loathing

A private-practice ophthalmologist from Seattle, who sometimes uses EMR at his affiliated hospital, offered a cautionary tale that's in line with the fears commonly expressed by skeptics. “The system is cumbersome, incompatible with any office system, and unforgiving. Each encounter has a series of check boxes that must be filled in or you cannot proceed,” he wrote. “This is extremely time consuming and prevents time with the patient. All in all, EMR is expensive, wastes time and money, and does not deliver value.”

Those sentiments were echoed by many who took part in our survey, and they manifested as a fair amount of resistance to EMR. Although a combined 41% of respondents plan to adopt EMR either this year or next (see Figure 1 below), over one-third (36%) have no current plans to pursue digital records, despite the federal mandate, enacted a year ago this month, requiring EMR use by 2014.

Younger practitioners seem more willing to pursue EMR. The percent of respondents planning to adopt EMR by 2011 jumps to 54% among those who've been in practice for 20 years or less (years in practice ranged from one to 40 years among respondents).

Smaller practices, however, were less inclined: 24.5% of practices with just one or two doctors on staff indicated plans to adopt EMR in 2010 or 2011, compared with 40.1% for all respondents (which averaged 4.6 doctors per practice) and 63.6% for practices with five or more doctors. “In a one-man office, it is overkill,” wrote one reader from New York. “Maybe in a multispecialty practice it makes sense.”

Those with just one practice location also fell below the average, with 30.2% reporting plans to adopt EMR either this year or next. By contrast, 50% of respondents who have satellite offices are planning to do so.

Some are pursuing EMR more out of obligation than enthusiasm. “I build my own computers/servers/networks and my house is completely computerized, yet even I know EMR for ophthalmology is a step backwards from pen and paper in terms of productivity and cost,” wrote a Virginia-based cornea specialist, part of a 22-physician group that's on the verge of signing a seven-figure contract with a vendor. “Even with improved collections from more accurate automated billing, EMR won't make up for the expenditures.” He said the practice anticipates “significantly decreased productivity” in the first year after adoption and “huge expense” over the first five years — a one-two punch he describes as “a classic lose/lose scenario for ophthalmology.”

Cost was clearly the biggest concern reported in our survey results (see Figure 2). Presented with 14 likely EMR obstacles and asked to rank the influence of each on a 1-5 scale, 83.3% cited EMR's upfront cost as having at least some influence on their reason to delay adoption, and just over half of those who cited cost as a factor ranked it as “extremely influential.”

Furthermore, when asked to select the one factor on the list that they considered their single biggest impediment, 30% chose “the upfront cost is prohibitive.” The ongoing monthly maintenance cost of an EMR system — second-highest factor in the rankings, cited as influential by 73.5% of respondents — reinforced that cost concerns are pervasive and must be overcome.

The federal EMR mandate (some would say meddling) offers incentive payments to soften the blow, beginning in 2011 for those who can prove “meaningful use.”

Our survey results found consequences both positive and negative for attitudes toward EMR adoption stemming from the federal intervention.

The third-most significant factor seen as a reason to delay EMR in our survey was lack of details on requirements an EMR system must include to allow practices to obtain the incentive payments. “With so many current systems and no firm government standards issued, which vendors will survive?” wrote one reader from New York. “I would hate to make a $70K decision only to find that the software isn't government approved and the vendor just abandons ship.” Still, 81.4% of respondents said their top priority when adopting EMR will be to qualify for payments/avoid penalties, and nearly half of them considered it “extremely important” (see Figure 3).

Growing Pains

Adapting your workflow to fit EMR, and customizing your EMR system to suit your practice, are the largest non-financial concerns of readers. Understandably so: when asked how much of their staff 's time is devoted to documentation, the responses clustered around 30%, although a sizable group (16% of survey respondents) put the number at over 50% of staff time. With so much day-to-day effort expended on documentation, delays and errors can send shockwaves through the practice.

“As a former Navy ophthalmologist, we were required to use EMR. It reduced our throughput of patients by 40-50% even in the most adroit of users,” wrote Virginia's Gary Tanner, MD. “I recognize that some of the ‘ophthalmology specific’ EMR systems are superior to the DoD system, but it is still prohibitively expensive and inefficient.”

“In our small practice, the same doctor sees her patients over and over, knows them well and rarely needs to retrieve more than a few previous findings,” wrote an ophthalmologist from Michigan. “The time to input EMR data and the time spent retrieving the information will greatly exceed that of our current process.”

Subspecialists face even higher hurdles. Patrick Caskey, MD, a retina specialist from California, wrote that “even ‘ophthalmology-friendly’ EMRs are still not optimized for retinal practice management.”

When assessing the impact of EMR on workflow, “doctors sometimes focus just on the data intake phase of the exam,” says Jim Messier, vice president of sales and marketing at MedFlow. He encourages a broader view that takes into account time saved in scheduling follow-ups, generating reports and prescriptions, and automated coding/billing.

To hasten the transition period, EMR systems must be as flexible and adaptable as possible. However, 61.8% of respondents said the EMR systems they had tested were not user friendly, and 60.8% said that were not tailored to ophthalmology practice. “We are very paper dependent and have fear of the conversion process,” wrote Christopher Wood, MD, of Arlington Heights, Ill. “Our future EMR needs to have excellent support and be very user friendly to make the process less onerous.”

Indeed, the vendor's reputation in serving the ophthalmology field strongly influences prospective customers. Seven out of 10 ophthalmologists in our survey who have researched the EMR market and found the experience unsatisfactory said they were concerned about entering into a long-term partnership with vendors who lack a track record that speaks well of their products and services (see Figure 4).

Despite the crowded field of systems available, “EMR will never become a commodity product” in which systems are essentially indistinguishable and compete solely on price, says Mr. Messier. “Notable differences will always exist in terms of software capabilities and level of company support.” Avoid companies that cut corners on staff training and system deployment for the sake of offering lower prices, he cautions. Mr. Messier says that MedFlow's use of COAs, COTs and COMTs for training purposes enabled the company to offer its customers CE credits through JCAHPO for some of the training they provide at conferences, and even for some community college courses.

Asked if they thought EMR adoption would improve the quality of care they provide, 78.4% of our respondents said no (see Figure 5). Inflexibility in data recording and reporting requirements seem to be concerns of many. “When I get EMR records from other offices, I receive seven pages for each office visit, most of which are default entries,” one ophthalmologist told us. “Each office visit notes that the lashes were examined. We all know that's not true. It's just the computer default printout when the doctor/tech doesn't alter the templated data.”

Continuing in that vein, another doctor commented that “many times a consult to a subspecialist is totally worthless because a generic EMR report is sent back not revealing much more than we already knew about the patient before referral.”

Another doctor mentioned that when he visits physicians as a patient himself, the doctor is distracted by the data-entry process. “He/she is focused on the EMR and not on me.” Many share that concern: in our survey, 69.7% of respondents worried that EMR would take away from their time spent with patients.

Abort, Retry, Fail?

EMR packages have been available almost as long as the personal computer itself. But while the technology has evolved dramatically since those early days, physicians' attitudes haven't. Burned by early experiences with unsophisticated software, or mindful of horror stories passed around among colleagues, doctors resent being forced to make a sea change in their operations that lacks clearly articulated benefits.

With ophthalmologists voicing strong concerns about both the initial cost and the monthly maintenance costs, vendors would do well to nail down the ROI for prospective clients. Given the importance of accurate budgeting to the success of an ambitious investment like EMR, a majority of our survey respondents (61.8%) said they preferred all-in-one pricing rather than a-la-carte options that would let practices put together a system piecemeal (Figure 6).

Flexible pricing can help ease the transition to EMR. Last year, NextGen began offering subscription-based pricing for smaller practices that does away with the upfront cost in favor of a flat-rate monthly expense. “Given the current economic state, many smaller practices simply can't afford the initial capital outlay associated with purchasing servers and software licenses,” said Patrick Cline, president of NextGen Healthcare. To reduce risk and uncertainty, NextGen also recently began offering a money-back guarantee.

Future installments of this series will look in detail at how EMR vendors are working to break down barriers to EMR adoption — and everyday use. “You're not going to get paid for ‘meaningful use’ by buying something you don't use,” MedFlow's Mr. Messier sums up. OM