The Efficient Ophthalmologist

The Joy and Headaches of EHR Conversion

Normally, this column is about efficiencies we can achieve in our practices, but with EHR, the elephant in the room is the clinic time lost due to navigating the charting and coding ergonomics of the system.

My staff often laughs at this 51-year-old for my resistance to a complete personal and emotional buy-in, considering my love for staying ahead of the curve and avant-garde approach to surgical technique and technology. I am not, however, waging war with the concept of EHR, which we implemented 18 months ago in each of our offices, but rather with the impact full compliance has on my clinic flow and overall efficiency in comparison to paper charting.

That said, let me take you on a brief journey through our integration of EHR, coupled with a few potholes encountered along the way, before concluding with several caveats on purchasing a system.

The Good, the Bad and the Ugly

In our practice, all aspects of billing, e-prescribing, PQRS, patient scheduling, exam findings and diagnostic testing are now captured by our EHR system, which I affectionately refer to as “the Borg.”

On the positive side, EHR has streamlined the coding-billing-compliance process, and I will admit that having OCT, topography, visual fields, angiography and other diagnostic data quickly available in the lane is helpful.

EHR has further allowed us to data-mine to identify patients who may be eligible participants in our busy research department. I am still slow with data entry — thank goodness for my scribes — but I am learning. Honestly, I wish EHR were voice-activated and as intuitive and user-friendly as my iPhone or Droid.

Because administrative functions such as billing and scheduling are straightforward and emulate earlier generations of healthcare business systems, adoption by this segment of our staff, who helped evaluate the different systems we were considering, was smooth and immediate. Though the technicians climbed on board somewhat reluctantly, they have embraced this mandated change. However, they are now much slower with data entry from the work-up. They spend time at the end of each afternoon initiating the charts for the next day's patients to get a head start and avoid bogging down clinic more than necessary.

Some staff members like EHR because it makes them more efficient, but a doctor's perspective may be a bit different.

The Transition Blues

Many practices find it important to reduce clinic volume during the first few months of integration as they try to offset longer patient waiting times caused in large part by the cumbersome navigation of the screens necessary to enter proper documentation. Even with 18 months of experience under our belts, clinic runs more slowly due to the time required for the technicians to record their findings and the scribes to document the doctor's exam. At the conclusion of the patient encounter, much time is still required to complete the coding, e-prescribing and PQRS data.

I can then either go into the next patient lane to begin the exam and enter the data myself, which takes away from the face time spent communicating with the patient and family, or wait until a scribe is available. Even in the fastest hands, this process is, without question, significantly slower than paper charting and check-box marking on the super bill. One smart thing I did at least, was to install touch-sensitive, wall-mounted flat-screen monitors and a dropdown keyboard and mouse in the hallway between my lanes, so that — as I did with paper charting — I can look at the technician data and diagnostics tests before I enter the room and begin to formulate my plan. This allows me more time to talk with the patient face to face.

Troubling Trends Emerge

From a practical standpoint, as a result of the experience from early adopters, several trends are coming to light with sobering implications:

Many doctors concerned about the cost and implementation and disruption of EHR are merging or selling their practices, and in some cases, retiring earlier than they would like. Some physicians nearing retirement have calculated that it is more fiscally prudent to pay the penalties rather than invest in EHR.

One troubling issue that has already caught the eye of the federal overseeing agencies is the “copy forward” capability of EHR, whereby prior examinations, diagnoses and treatment regimens are forwarded to a new patient encounter with a few clicks of the mouse. Oh, and yes, typos and medications are copied forward as well, which is what first alerted the feds to this practice. Developed as part of the “efficiency” of EHR, this aspect has dangerous implications.

I served as an expert witness for a malpractice case in which a prisoner with documented uveitis and significant glaucoma was followed by a private-practice ophthalmologist who documented that the patient was a steroid responder. Though by testimony the steroids used to treat his uveitis were discontinued, the EMR records carried forward the diagnoses and treatment plan, which never demonstrated that the steroid medications were withdrawn. The patient ultimately went blind bilaterally while in prison, and sued on the grounds that his glaucoma and subsequent blindness were caused by the doctor's negligence in not ordering the discontinuation of the steroids.

Quick Tips on System Selection

There are pros and cons to each of the systems available. Be sure to do your due diligence with hands-on demonstrations of the systems you are considering. Make certain that your chosen system is fully certified, which is the responsibility of the vendor, and best meets the needs of your scheduling, billing and clinical aspects of your practice.

Make time to send staff and/or personally visit a practice experienced with the EHR system you are considering. Ensure that the company is adequately staffed for both installation and ongoing IT support. Determine if the system you are considering can easily transfer data to a different platform if your vendor were to go out of business.

Following installation and in-servicing, you will need repeated customer support phone calls to work out the bugs, further customize the system to your practice culture, and learn to use the higher-order, more complex functions which your EHR is able to provide. OM

Steven M. Silverstein, MD, FACS, is a cornea-trained comprehensive ophthalmologist in practice at Silverstein Eye Centers in Kansas City, Mo. He invites comments. His e-mail is ssilverstein@silversteineyecenters.com.