EMR: Glaucoma Goes Digital

What features are most beneficial to simplifying your practice?

By Samantha Stahl, Assistant Editor

All subspecialties have their own preferred features when it comes to implementing EMR, but glaucoma in particular faces a unique set of challenges. As EMR technology matures, more and more systems are offering specialized templates and components to make management of the disease a little easier. While some of these settings can simplify care, others threaten to cause needless hassles for both doctors and practice staff. So which settings are worth the investment, and which are simply a chore? In this feature, glaucoma specialists discuss their biggest likes and dislikes with the EMR experience.

Data Review

Because of the need to track disease progression over time, glaucoma is an especially big benefiter from the technological capabilities of a well-designed EMR system. Flash back 15 years ago, when all imaging was done on film and reviewing data was a bit of a juggling act. Physicians were forced to repeatedly flip back and forth between multiple files while coming to clinical decisions. Now, with the ability to digitally look at data and images simultaneously, the burden is alleviated.

Michael Rotberg, MD, of Charlotte, NC, says that his EMR screen gives an overview of IOP over time, as well as a history of peak IOP, target IOP and the ability to graph past IOP measurements. Quite a bit more streamlined than thumbing through paper files to compare numbers. The system (Medflow) has a built-in IOP adjustment for pachymetry, and all IOP readings list the time of day the measurement was recorded — taking accuracy one step further. The screen also shows dates of previous visual field testing, gonioscopy, OCT and a snapshot of the interpretation for all the tests in one place.

This kind of specialization is becoming more and more common in systems that cater to ophthalmology, so if you're in the market for an EMR — ask about customizing options. At this point, they should be standard.

“It's nice to be able to tweak the system based on our practice's needs, rather than changing our practice to fit the system,” says Tania Marcic, MD, a glaucoma specialist at the Katzen Eye Group in Baltimore, which uses the NextGen EHR and practice management system. She uses a specific glaucoma flow template to track all relevant exam parameters, but each of the other physicians in her practice use a template of their own.

“You have to pick a system that can easily be modified for any specialty or generalist, because I think it's going to be hard to find a single-specialty practice in the future,” she says. You also want to be able to easily navigate notes from any prior exams with a retina doctor or other sub-specialist in the practice.

Of course, the other big hassle with glaucoma is medications. Dr. Marcic says the ability to save preferred medications into a patient's record, rather than interrupting a conversation to search through a national database at each appointment, is a big time saver.

Michael Tran, MD, of Westminster, Calif., who uses Com pulink's Ophthalmology Advantage system, says that he is able to graph IOP and have a correlating plot of medication changes or other treatments, like laser therapy or surgery. “In a glance, you can see the effects of the treatment,” he says. Being able to pinpoint and attribute positive or negative changes to a medication that is saved in the patient's file eliminates the risk of re-prescribing something that didn't work for the patient years ago, and likely won't work now.

Patient Compliance

Getting patients into the office and taking drops consistently is half the battle. A constant source of physician frustration, EMR systems are now stepping in to nudge patient compliance in the right direction. Dr. Tran, for example, says he can identify which glaucoma patients tend not to keep follow-up appointments and send them reminders from the system.

Electronic prescribing has become a popular feature, and rightly so. Aside from cutting down on paper, it offers convenience to practice staff, as well as pharmacies and patients. An added benefit is the ability to track whether or not a patient filled a prescription, which may be just the right trigger to have a compliance discussion.

“If a patient says, ‘I just happened to run out of my eye drops last night,’ and I see that the last time they refilled their latanoprost was four months ago, I can have a sense of their compliance,” says James Brandt, MD, at the University of California's Davis Eye Center. The UC Davis Health System uses Epic EHR, which allows physicians to review pharmacy records with some insurers. He can then show the pharmacy data to the patient and have an honest discussion about whether it is time to move on to a surgical solution, or switch prescriptions. “When they say they're religious about taking their meds but the pharmacy data shows they haven't refilled their meds in six months, that's a big red flag. Having access to this data has been a game-changer for me.”

While some physicians say they wish their system had the functionality to remind patients daily to use their drops, others, like Paul Bryar, MD, of Chicago, say the reminders for a patient taking medication three times a day would probably be too cumbersome. One EMR feature he does appreciate, however, is the ability to print and give patients instructions for proper instillation of glaucoma drops. If patients know just what to do with the medication, compliance may improve.

Set-Up

While trendy iPads or lightweight laptops seem like a convenient, fun way to bring EMR into the office, Dr. Brandt says those small screens may be big time drains over the course of the day. “With a small 19-inch screen or laptop, you're going to waste an enormous amount of time toggling between windows. It can easily add up to a minute or more of clicking and mousing for each patient.” So if you see 30 to 40 patients a day, well, do the math. Instead, he recommends getting the biggest monitor possible. Since glaucoma specialists need to view images and textual data simultaneously, the investment is worthwhile.

Dr. Brandt, like many ophthalmologists working in an academic or hospital setting, had to deal with a larger entity making most of the choices about how his EMR would be implemented, but insists that no matter how much the powers that be may refuse to dish out for a larger monitor, “do not take no for an answer. Get a big screen or dual monitor system. Anything else simply does not work for ophthalmology.”

Future Developments

Comparing the systems that early adopters of EMR used 20 years ago to current technologies is like comparing night and day. Dr. Bryar says that earlier versions didn't have much to offer in the way of glaucoma functionality. While major strides have been taken to streamline systems into today's offerings, there is still room for improvement.

“In EHR for glaucoma, as we understand more about the disease and risk factors, the ability to make summaries more robust will improve,” says Dr. Bryar. He believes that in the future, systems will need to do a better job of integrating ancillary tests.

“Glaucoma specialists in particular require intensive image management with visual fields, OCTs, etc., so you want to find an EMR that provides seamless integrated image acquisition without having to purchase additional products,” says Kyle Smith, MD, founder and CMO of Integrity EMR. His system has built-in data acquisition so that images can be imported and viewed from diagnostic equipment without any software add-ons necessary.

“The Achilles heel of all EMRs as they exist now is pulling in information from all the diagnostic instruments we use,” says Dr. Brandt. He foresees DICOM compliance improving over the next decade, once vendors have more incentive to expend the effort to get output from ophthalmology-specific equipment. DICOM standards have now been ratified for most ophthalmic diagnostic instruments,, but it will take a while before manufacturers build appropriate connectivity into their hardware and DICOM-compliant output into their software. It will then take years before non-compliant devices are replaced or upgraded in doctors' practices.

“DICOM will be essential for rapidly understanding glaucoma,” says Dr. Bryar. He hopes that by developing and adopting standards, physicians will be able to look at risk on a population-based level by examining one particular feature of an OCT, or other test, that may signify risk.

Future improvements in technology will not only make diagnosis simpler, but patient care more effective — that's worth waiting for. OM