Using Forum Without an EMR System

A data management system helps one practice make significant time gains.

By Michael S. Jacobs, MD

About 3 years ago, I was in the process of redesigning the practice that I'd joined, peeling away the floral wall-paper and linoleum floors and rethinking the 20-foot exam lanes and 8-foot ceilings that my partner had built in 1973. We changed the décor to preserve my sanity, but we also wanted to improve the practice's efficiency to advance our bottom line. In the end, our general ophthalmology practice benefited enormously from adopting the Forum data management system.

Inconvenient Imaging

As I was designing the new facility, I tried to identify inefficiencies in our current space. Aside from the typical layout and exam room issues, I kept returning to the time required for us to review all of our reports.

We're a little unique in ophthalmology because we spend so much of our day looking at topography, OCT or other images in printed reports. I was frustrated as I watched my technicians stand by the eight-inkjet printers connected to each of the machines around our office. I was tired of spending my time flipping through charts, trying to find the studies I wanted. Just reviewing the data was frustrating. I'd have to lay all of the visual fields out in front of me to evaluate the total deviation and changes over time. In a paper chart, and even in the EMRs that I've seen, we don't really have the ability to see all of these different historic data points at one time.

In addition, patient education wasn't great in our practice. For example, I could look at the OCT on the way into the patient room and tell patients if they had an epiretinal membrane or some cystic macular edema, but much was lost in a strictly verbal explanation. If I could show the patient a picture of the OCT, it would certainly ease my efforts in describing the problem and making the issue clearer to them.

I knew there had to be a better way to run our office.

A Better Way

With these quality issues and inefficiencies in mind, I turned to the folks at Zeiss and said, “I've got all of these different pieces of equipment. Is there a way to connect all of these machines to a server and pull up the data in the exam lanes?” They said, “Sure!” That conversation led me to adopt the Forum data management system.

You might ask, “Why not just get an EMR system?” EMRs have some of the features I was looking for, but 3 years ago and to this day, there is no clear front-runner in the EMR race. What's more, I was happy with my paper chart. The issues I was trying to solve were wasted time and inconvenience with printing multiple reports, finding those reports when I needed them and having the images in the exam lanes to show my patients. Forum addressed all of these issues.

Cost was also a factor in converting to a data management system first because while EMR systems are expensive, Forum is very reasonably priced, especially for a small practice like mine.

Lastly, I knew that in the future, when I adopted EMR, I'd be able to integrate Forum with any EMR system, and I'll already have Forum's more robust data viewing suite to accompany the new EMR system.

Forum's Modality Work List

Peers sometimes ask me, “How is Forum really different than an EMR system? What's the point?”

There are a few key differences. One feature I learned about when I first began using Forum is something called the Modality Work List.

When patients come into my office to have any kind of testing, a technician enters the patient's information just once at any computer in the office. Throughout the rest of the patient's visit, any device used on the patient—an IOLMaster (Carl Zeiss Meditec), topography, OCT and so on—allows the technician to select from a drop-down menu of tests the patient is scheduled for that day.

There's no more time-consuming repeated entry for each patient at each machine, and we see fewer errors resulting from typos or misfiled data for patients who have the same or similar names.

Data Storage and Custom Views

Another robust feature of Forum is the ability to choose custom viewing options. The Forum shows me a combined report, which I consider to be the key to the future of image management in that it has the potential to actually enhance outcomes. Forum gathers the data from the HFA single-field analysis, the OCT and the RNFL thickness reports, and then marries them into a single report. In this combined report, we see a beautiful melding of structure and function. At a glance, I can clearly identify, for example, an inferior defect in the right eye that marries nicely with superior RFNL problems (Figure 1).

Figure 1. This combined report contains data from the HFA single-field analysis, the OCT and the RNFL thickness reports. Here, we see a beautiful melding of structure and function.

Flexible data storage is key to making reports customizable. All of the data from my devices is stored in its raw form on the server. I then choose from a set of options to determine how I view this information in our exam rooms and how Forum compiles that information into a report. Again, for a glaucoma suspect, I choose which reports I want to see and how I want to orient those reports on the screen. I might look at 4 years of visual field data at the same time as the optic nerve and the RNFL. Viewing all of this information together helps me synthesize it and make a more informed diagnosis (Figure 2).

Figure 2. Viewing various types of historical patient data all at one time, all on one screen—allows for a more informed diagnosis.

My hope is that in the future, each physician will be able to pick and choose which pieces of information he or she wants to see in a given report so we'll all have our own truly custom reports. For example, one doctor may prefer to evaluate visual field total deviation, pattern deviation and certain aspects of the OCT reports, along with disc photos. I think that because Forum archives the data in its raw form, we'll be able to select those pieces of information that fit how we like to treat and monitor our patients.

Recapturing Spare Time

Forum helps me save time that was previously spent printing and flipping through charts, and allows me to do what I think is a better job of analyzing data. It saves me time in a few other ways, as well.

For example, Forum helps me generate time in our cataract clinics. Several years ago, we adopted silo scheduling for patients with cataracts in an attempt to improve conversion to premium intraocular lenses. Forum has given us the perfect opportunity to streamline that process.

Before we had Forum, I would walk into a patient's room during cataract clinic, greet the patient and perform an exam. We would discuss the timing of cataract surgery. If the patient expressed interest in surgery, then we had a lengthy discussion regarding the different lens choices.

Of course, when you're using premium lenses, chair time is key. I was having a conversation about presbyopia-correcting lenses, toric lenses or conventional lenses with every patient, after which they'd move on to the surgery scheduler or come back for their measurements.

At that point, as I looked over the measurements from the OCT, the IOLMaster, the topographer and the manual keratometry, I might determine that a patient was not a good candidate for a premium IOL, such as a multifocal lens. I might find that a patient needed a toric lens, even if I didn't recommend that during our discussion because the patient's eyeglass prescription didn't reveal significant astigmatism.

These kinds of findings made it necessary to call or see the patient again and have another lengthy discussion. It was a time-consuming burden because I didn't have the information when I needed it. The Forum system gives me all of the information up front, averting the need for this type of back and forth. (See “Time Saved in the Cataract Clinic,” below.)

Forum also saves me time with our glaucoma patients because patients can come in and have their visual field testing and OCT scans when I'm not in the office. I evaluate these results at my leisure and review several years' worth of data all at one time. The system is robust and flexible, so it helps me save valuable time.

Time Saved in the Cataract Clinic
When I walk into an exam lane for one of my cataract clinics, my staff has already pulled up topography and a OCT macular cube for the right and left eye on Forum. When I walk into the room, I shake hands and introduce myself to the patient. I glance at my screen, and within about 5 seconds, I know this individual has a couple of diopters of astigmatism and is best suited for a toric lens or maybe a conventional lens with spectacle correction. A presbyopia-correcting lens is probably not the best bet. That saves me a good amount of time—perhaps as much as 10 minutes, depending on the patient—that I would have spent explaining the nuances and pros and cons of presbyopia-correcting lenses. I'm able to use that time somewhere else.
When I walk into this room and meet the patient, I can see that the topography looks good, but a glance at the OCT scans reveals that this individual has some edema in the retina. As it turns out, she actually has a neovascular membrane. I still complete my exam. I tell the patient that yes, she has cataracts, but I don't need to go into the lengthy discussion about cataract surgery and all the different lens options at this point because this patient needs to see a retina specialist. Having the information I need right in front of me at the start of the exam saves an enormous amount of time.