Going Paperless: One Step at a Time

Here's how to use health IT to position your practice for future success.

By Sean McKinney, Contributing Editor

Most ophthalmologists understand that they'll need to do more with less to meet the demands of the future. One strategy is to gradually adopt health information technology (IT). If implemented correctly, an IT solution can significantly increase annual revenue, eliminate the need for additional doctor hours and reduce errors and redundancy in testing. The key to success, say those who are engaged in this process, is to take a sequential approach.

"You're kidding yourself if you think you can eliminate paper instantly," says retinal specialist Vincent R. Vann, MD, PhD, of Edinburg, Tex. "Moving toward a paperless office is a complex process, which is best done in stages. Implementing a digital imaging and data management system in your practice should be the first of many steps in the process."

Health IT includes practice management solutions, electronic medical records (EMRs), and — the primary focus of this article — a middle structure that streamlines the gathering, archiving and analysis of opthalmic data and images. Here is how to begin or continue the journey to meet the challenges ahead.

How to increase efficiency — for real

Expect an initial drain on resources and a temporary reduction of productivity, particularly if you're incorporating an EMR system. However, make sure future gains in both of these areas will more than make up for the up-front investment of time and effort. Consider these goals:

■ Streamline data collection. Michael Jacobs, MD, owner of Athens Eye Associates of Athens, Ga., has held off on buying an EMR system, but he improved his practice's efficiency with an image-based data management system, FORUM (Carl Zeiss Meditec, Dublin, Calif.). Because of the Modality Worklist module of FORUM, which facilitates a transfer of data to ophthalmic instruments, his staff enters patient demographic information only once, saving time that used to be spent re-entering information every time he ordered a test.

All diagnostic instruments in the retinal practice of Vincent R. Vann, MD, PhD, are connected by hard wire (left) to a MAC server (right), which provides him with remote access to images and patient data 24-7.

"Once that data is entered, it's available anywhere in the office, or remotely through a secure server," says Dr. Jacobs, who is a solo practitioner. "Instead of printouts, I access comprehensive patient data through drop-down menus and thumbnails that expand into detailed images. Meanwhile, valuable office space once occupied by five printers is put to much more productive use."

IT systems that offer similar features include EyeRoute (Topcon, Paramus, N.J.) and DigiVersal (Kowa Optimed, Inc., Torrance, Calif.).

■ Reduce errors. "Each ophthalmic instrument has a separate database. Any data redundancies or errors across these different instrument databases can lead to costly and time-consuming errors," says Dr. Vann, who's also an early adopter of the FORUM system.

"I'm compulsive about accuracy in data entry. Before using FORUM, when we entered patient data on each separate instrument, we saw an incredible number of human errors. That problem has been significantly by using FORUM."

■ Eliminate redundancy. Paul S. Koch, MD, medical director of Koch Eye Associates in Warwick, R.I., notes that intelligent use of health IT can break a costly "addiction to protocol."

He explains: "The technician takes a patient's history, checks vision and checks the pressure. But what if the patient was seen only 30 minutes earlier by one of our other physicians and wants a consultation? When the patient gets to our second office, should every test be repeated simply because that's our protocol, or should the technician take the patient to the exam room and do something more productive?"

He noted that inter-office connectivity would send the patient immediately to an exam room, where the consulting physician could evaluate the latest test results from the other office.

"The practice probably would experience less back up," observes Dr. Koch. "Cases would move along more quickly. The additional patient wouldn't disrupt the office schedule or patient flow."

How to provide faster — and better — care

Time will be increasingly of the essence.

■ Spend more time on the patient, less on busy work. Because FORUM supports the requirements of Digital Imaging and Communications in Medicine (DICOM) standards, Dr. Vann is able to order all imaging tests, then retrieve the final test results, and manipulate 3-D OCT scans and other images for analysis. Using FORUM's data management system, Dr. Vann creates "work lists" for each test he orders on a patient. "These work lists tell my technicians exactly which instrument to use and which test protocol to use for each patient," he explains.

"In each exam room, I pull the images up on large dual 24-inch screens, allowing the patient and family to view the results as I interpret them," he continues. "They can see the test results instantly while I show them why, for example, another injection or laser treatment might be needed. I can provide meaningful education on the condition and the prognosis.

"I can closely monitor progression or stability of a patient's diesease by viewing and comparing images that are weeks, months or even years apart," says Dr. Vann. "For example, I can view and analyze an OCT scan or angiogram side-by-side right next to a visual field result. This makes me a better diagnostician and allows me to include the patient and family in care planning."

This benefit is significant because "meaningful use" of health IT, as defined by the U.S. Department of Health and Human Services (DHHS), calls for "engaging patients and families in their care," among other goals that you will be asked to meet to qualify for full reimbursement in the years ahead.¹

"With this technology, the ability to analyze each individual visual field is dramatically improved," notes Dr. Jacobs. "At a quick glance, I'm able to identify details in the visual field, such as reliability indicators, as well as mean and pattern standard deviations, thereby improving my interpretation and ultimately the quality of care my patients receive. I could never achieve this by flipping through printouts in charts."

■ Increase compliance and outcomes, reduce needless visits. Making an image-based data system a central part of care can help meet another meaningful use standard for health IT: improving the quality, safety and efficiency of care.¹

"Imagine you have a non-compliant patient with cystoid macular edema in your chair," says Dr. Jacobs. "When he sees the obvious color changes on the thickness map of his OCT scan as well as the large cysts in the cross-sectional view, he'll be more likely to start using his drops, as recommended, four to six times a day. At the next visit, the patient sees the colors and cysts have improved, and he becomes even more motivated to comply. He may not need to come back as frequently.

"This same dynamic applies to glaucoma and other chronic conditions. It's a win-win for the practice and the patient."

FORUM allows side-by-side views of images from fundus photography and Cirrus HD-OCT. Here, we have a patient with cystoid macular edema associated with a branch retinal vein occlusion before an intravitreal triamcinolone acetonide (Kenalog) injection (top) and 1 month after the injection (bottom).

How to maximize IT impact on your practice

Before adopting a health IT system, estimate how much it will affect your finances, based on how you plan to design your practice around the system. Lean on the vendor as a consultant before making a final decision. Seek independent opinions as well. Consider these key points:

■ Evaluate potential cost savings. Dr. Jacobs estimates that the efficiency of his IT system enables him to save up to 4 minutes per patient visit for those afflicted with glaucoma or retinopathy. Because this activity accounts for 45% of the 13,200 visits he and his optometrist complete per year, the savings in time adds up to 396 hours — the equivalent of more than one-fifth of another doctor.

"Obviously, this savings gives us a lot of capacity and efficiency we didn't have before," he says. "Gone are the days when we could afford to spend time flipping back and forth through OCT scans, visual fields, IOLMaster readings, corneal topography scans, fundus photographs and other data. We don't make printouts or go looking for missing folders anymore."

■ Evaluate potential revenue gains. Amir Arbisser, MD, whose practice includes 20 doctors at five locations in Iowa and Illinois, advises ophthalmologists to use the precious minutes that IT saves to increase patient volume in small amounts. "If a practice can add two to four patients per clinic day through increased efficiency, the gain can ultimately be significant," he says. "If you calculate $200 in revenue per patient encounter, that adds $400 to $800 per day, which can total a six-figure yearly increase despite a challenging economy."

"We need to gradually ramp up productivity," acknowledges Dr. Koch. "We're slowly doing it — first by increasing each physician's load by one patient per half day, then another, then another."

■ Identify your logistical needs. Health IT can solve many problems, but it also can create challenges if you don't customize a system for your practice. Alan B. Aker, MD, who operates the Aker Kasten Eye Care Center with his wife, Ann Kasten, MD, in Boca Raton, Fla., says they're seeking a solution that will help their practice and surgery center better manage clinical visits and about 2,500 cataract extraction procedures a year.

For them, an ideal system would eliminate repetitious entry of data. In addition, it would allow nurses, surgical schedulers, technicians, transportation team members, billing personnel, surgical counselors and others to access the chart at the same time.

"As we plan to open satellite offices to our north and south, EMR becomes even more important, eliminating the need to carry charts around," says Dr. Aker. "We hope to adopt a user-friendly system that will help us accomplish these goals."

Envisioning the Perfect IT Solution By Ella Faktorovich, MD We obviously must manage increased growth in the future without eroding the quality of care or financial health of our practices. But how? Many solutions will be delivered by emerging informationbased technologies. Our most important objective will be to identify methods of practice that are critical to our success; then identify the technologies that will support these methods of practice. All aspects of what I call an electronic patient record (EPR) — demographics, environmental, billing and medical record — will need to be kept in one database, accessible at a touch of a button from anywhere in the world at any time. This system, going beyond advanced systems that allow access to data through servers inside practices, should allow us to use any browser-enabled computer or mobile device to review patient test results and information. The system should feature quick and intuitive data entry that will involve minimal typing, minimal drawing and very short pull-down menus. It also should allow voice recognition for carrying out data entry and most tasks. The system will have artificial intelligence to present a screen or a menu based on a particular environment, depending on who is seeing the patient (front desk, technician, optometrist or surgeon), and which exam is being performed (yearly routine visit, cataract, diabetes, retina and so on), and the history of a particular patient. Navigation will need to be easy, intuitive and fast. Think iPad and iPhone. We should be able to touch a screen to move between fields and enlarge or minimize images and data. iPad-type technology should be in every exam room and operating room. The patient's record should also be connected to all of the diagnostic testing and surgical technologies. And it will need to be platform-independent. The data should flow immediately from topography, OCT, A-scan, angiography, tonometry, lasers and phacoemulsification machines into each patient record. We can accomplish most of these goals now. The key will be pulling the technologies together. There needs to be as little dependency as possible on any type of hardware, software or operating system. For example, a client computer should be able to accommodate more than one hardware platform, such as a PC or MAC, and run on any operating systems, such as multiple versions of Windows, OS-X and Linux. Any type of browser, such as Internet Explorer, Mozilla and Safari, should be enabled. If we achieve these goals, we as physicians and managers of our practices will never have to worry about accessing data — the lifeblood of our future practices.     Dr. Faktorovich is founder of Pacific Vision Institute, San Francisco, Calif.

Pulling it all together

These physicians say it's not wise to adopt health IT alone. Consult with an IT expert who can assess your practice and make recommendations. Watch developments in the health IT arena in the next few years as the movement toward digitally connected quality care continues to expand. Bottom line: an IT solution should increase precision and efficiency without compromising operations.

"By going at the right pace, we can make significant progress in this area," says Dr. Vann. "We'll soon have no other choice." OM

Reference

1. Blumenthal D. Launching HITECH. N Engl J Med. 2010;362:382-385.