SPECIAL SECTION: EHR CONVERSION

Know These 9 Factors Affecting EHR Productivity

Key concepts to help you make a more informed purchase.

BY Dan Salamie, CPA, MSIE

All businesses must continually strive to achieve more with less. Managers are expected to beat their own prior performance and, in competitive situations, that of their rivals. Medical practices are doubly challenged by consistent cut - backs in their reimbursements that put a ceiling on revenue and — owing to the omnipresent role of third-party insurers — an inability to let prices adjust to supply and demand.

These constraints bring to the forefront the critical importance of productivity, both individual and collective. For the ophthalmology practice, productivity is measured by the number of patients seen per day. Anything that undermines this crucial metric impedes the success of the enterprise. Done right, EHR implementations can improve productivity by eliminating error and avoiding duplication of effort. Unfortunately, that is rarely the initial experience after migration to a mandated EHR.

During an EHR session at the AAO conference in Orlando last fall, Jeffery Daigrepont of the Coker Group observed: “You are unlikely to see any increase in the productivity from the transition to an EHR. You are doing it for compliance and remittance reasons and not to see more patients. Any software claim of improved physician productivity should be viewed with great skepticism.” Eventually, with progress along the learning curve, practices can use EHR as an enhancement rather than an impediment to productivity gains, but this requires a fundamental rethinking of office workflow dynamics.

As suggested by Mr. Daigrepont’s observation, structured productivity concepts are often missing from the EHR software selection process. To explore this, first study the structured productivity sidebar on page 55, then apply these concepts to EHR software elements. Below are nine key considerations that should inform your selection process.

1. Software Delivery Methods

The two basic software delivery methods are: (A) directly on the office network or (B) over the Internet.

Installing the EHR software on the office network forces the most network maintenance cost upon the office budget but gives the practice complete control of the network and the data collected therein. Enhanced performance is achieved because the server can route network and EHR activities separately, can perform more effective backup and recovery systems, plus isolate certain network-based EHRs from the internet. For those EHRs that can operate without a continuous network connection, allowing internet access only when necessary can improve security dramatically.

Internet-based EHRs reduce the office’s reliance upon network support costs, and have the advantage of making any update to the software transparent to the user. On the other hand, the EHR system will not work if your internet provider is down or if the EHR software server is down.

Though often presented as important, the difference between Web-based or cloud-based EHR access is how the software vendor pays his bill, and therefore irrelevant. The real issue is whether the design is desktop-based or internet-based. A few key factors that come into play include system response time, chance of screen lock-up and cost of network support. Be sure to discuss them thoroughly with prospective vendors.

2. Window Type

There are two types of software navigation: sequential and random. Sequential is a legacy type from DOS and even older command-line computer systems. Many Veterans Administration care points still use this system. This technology requires just as many clicks to obtain a target data entry window as it does to return back to the main menu, thus proliferating clicks. Macros are a method for coping with sequentially driven systems, as described below.

Random navigation is the modern approach to software. Switching between windows, resizing windows, displaying several widows simultaneously and working on any window is the essence of modern operating system design.

3. Navigation Type

There are three basic types of navigation within EHR systems: drop-downs, tabs and buttons. Each has its advantages and disadvantages.

Of these, the drop-down style of navigation can create efficiency problems. In drop-down lists, selection widths are narrow, and it is difficult to transition (left, right, up and down) in a straight line to the next list. Drop-downs require straight cursor motion, but we tend to make a curved motion from our wrist or elbow. On the other hand, dropdown lists are very useful to select a data entry or other input choice. The list makes sure that particular field has consistent range of responses and consistent spelling. For these reasons, an EHR system should rely on drop-down lists for input selection and not navigation menus. When using drop-down lists for input, the lists should be editable.

Tab windows can create a very effective navigation system. The tabs may have titles similar to the flow tasks for an office visit type like Family History, Patient History, Medication, etc. Some tab navigated systems change the color of the tab once data has been entered, and some will not let you leave a tab until certain fields are completed. Some will allow you to resize the tab selected window and allow display along side another such window. Tabs are a desirable feature, especially the ability to select which tabs are used and in what order of appearance.

What are Structured Productivity Concepts?

Footsteps, mouse clicks, scrolls and keystrokes (now simplified to clicks) are direct indicators of the productivity of a patient care system. The more clicks and footsteps it takes to process a patient, the less productive the care system. Although excessive footsteps may indicate poor office design just as excessive clicks indicate poor software design, it is likely to be an indication of rework. Since these productivity measurements required no great skill, anybody can observe and tally the counts. Normalize the results as a per patient ratio. An ophthalmology practice is a collection of work shops, which should be characterized as either part of the flow shop or the job shop. A flow shop is the set of patient intake tasks required to prepare the patient for evaluation in the job shop. In the flow shop, the practice collects data; in the job shop, it acts upon it. Reducing the number of clicks and footsteps during the flow shop phase actually results in the most productivity improvement for the ophthalmology practice. Software elements 1 through 6 in the main article result in the most flow shop improvement for the ophthalmology practice. The job shop is where the physician takes control of the patient and applies cognitive and procedural efforts, based upon the information collected in the flow shop. The patient and staff may travel between shops until the physician’s final cognitive decisions and procedures are complete. Whenever the ophthalmologist discovers a flow shop function is incorrect, incomplete or omitted, the physician should identify the flow shop person responsible and direct them to make the correction. Forcing the correction of rework perfects the office flow shop by establishing better procedures and eliminating physician interruption. If rework is detected during EHR installation, the source of the interruption must be corrected before additional software installation. Software elements 6 through 9 discussed in the main article result in the most job shop productivity for the ophthalmologist. Both flow shop and job shop productivity is dependant upon the office network functioning at peak efficiency. There are at least three important network service points. First, network support, provided by professional network specialists or in house, is required to make sure the office network computers have the same configuration, down to the deepest level of the operating system, including backup systems. Secondly, have your network support install the maximum RAM into all computers running the new EHR. Because EHRs are intense database systems, the more RAM available, the faster you can access screens, the more windows you can leave on your desktop, and the faster EHR report generators will run. RAM is to EHR what oil is to a car’s engine. Lastly, deficiencies are likely in the network bandwidth (download/upload speed) or uptime/downtime, even for those on speedy T1 internet connections. To document such deficiencies, it is necessary for your network support to install a computer directly into the internet provider modem. Bypassing your network system is the only way to document uptime/downtime and bandwidth deficiencies and prevent the internet provider from blaming your network configuration.

Buttons are commonly used to drive main menu selections. Buttons are also effective on a tab window when some alternative requires manual selection, such as to receive data from an autorefractor. If there are too many buttons, the user’s mouse hand is forced to change directions too often and becomes inefficient. The exception to this rule is the touch screen navigation, which allows for the fastest of all navigation systems.

4. Data Transfer and Import From Legacy System

All EHR vendors claim to have data transfer services included in the price or separately priced. The phrase may mean just the transfer of patient names, account number, addresses and telephone numbers. The service may or may not include an accounts receivable balance transfer. Transferring past visit data is rarely included — so be specific about what the EHR vendor is offering you.

It is important to note that many EHR systems have data import features. EHR representatives have little experience with this tool. On the other hand, accountants have extensive experience in transferring accounts receivable information from paper invoice systems to software, and from software to software. The productivity loss from using two different receivable systems can last more than a year, so including an accountant as part of the data transition team can be a powerful advantage.

5. Report Generation

The report generator is an office function and not part of the patient exam. A comprehensive report generator can produce a report from all fields across the EHR, practice management (PM) and image management (IM) modules. At the AAO conference, some EHR vendors claimed to have as many as 200 different premade reports, but few sales representatives at the EHR company knew the details of more than a couple. So it becomes the user’s job to look for the desirable reports. Many companies include too many fields for the report to be practical. A suggestion by an EHR vender to “make custom reports” is not a sufficient report generation option — address your practice’s specific needs and circumstances.

Bring examples of every report you routinely need and make sure they can reproduce a similar report. Next, confirm the report generator’s flexibility, which is important because the need for a new government or insurance company report can happen at any time. To determine if an EHR can produce a report across the EHR, PM and IM, ask for a report that includes patient name, address, last appointment date, next appointment date, outstanding insurance balance, outstanding co-pay balance, medication, allergies, most recent refraction values and a comment field from the most recent image. Such a report is designed to stretch across all EHR modules. Selecting the fields you want should be a simple matter of dragging and dropping the field name into the report. To understanding more about dragging and dropping to form a report, read and practice the spreadsheet tutorials for reports.

6. Keystroke Recorder, Scripting and Macros

The key to software efficiency is to standardize the flow tasks applicable to your practice style. Keystroke recording, scripting and macros are what make the software control of the flow shop tasks possible. To date, this is the only practical method for standardizing flow shop control within an EHR environment. During the macro recording event, the clicks on the software are memorized so they can be replayed by using just one click, which replaces many and simultaneously standardizes the flow shop. Furthermore, the recording is in a software language that can include full software development. Many vendors claim to have macros; challenge them to demonstrate a macro recording feature.

Although the macro language may not be included with any given EHR software, the functionality can be obtained via windows automation software. Details to make sure a given EHR package is compatible with automation software are available from the author by sending an email to: dsmail@att.net.

7. Displaying Multiple Images and Commenting Directly on Images and Reports

Many EHR systems include an IM component. Vendors typically offer image transfer services, including a guarantee to maintain the link as the equipment manufacturer updates its software. An IM equipment interface may be included or separately priced. Within an IM, there are two very desirable features: (A) displaying multiple images simultaneously and (B) commenting directly on the image.

Simultaneous image display is an obvious time and click saver. Side-by-side images of the retina from two different office visits, images of different types from the current office visit, or any combination thereof should be demonstrated by the vendor.

The ability to comment directly on the image or report is another significant click saver and efficient organizer. More advanced commenting systems provide drop-down lists where the ophthalmologist can select the comments, then diagnostic codes and/or procedure codes will be generated automatically. Appropriate sentences are automatically added to care plans and/or referring physician correspondence. Some of these advanced EHRs include palettes with modifiable drawing elements (size, color, location, rotation) that generate automatic codes, plans and correspondence.

For those EHR systems that rely on Adobe Reader to view PDF images, substituting Adobe Acrobat will provide the ability to comment and save these comments directly into the PDF file.

8. Coding Assistance

Diagnostic and procedure code assistance is an integral part of any EHR. The simplest use a check box system that resembles the superbill. Better ones also capture billing from the equipment image transfer events, commenting on an image, and even diagnostic and procedure drawings.

However, there is a caveat. There are legal problems concerning coding assistance, and with coding opportunity identification below. Audits can be triggered based upon a perceived cross-over between EHR versus PM interaction in the coding process. This issue needs to be understood by EHR users, but is beyond the scope of this article. Office management is well advised to research this matter with insurance providers and Medicare auditors. Cross-check the responses from these sources with the responses supplied by EHR vendors.

9. Coding Opportunity Identification

Whether this feature is called coding assistance or an integrated coding engine, it displays a comprehensive list of additional procedures or diagnostics consistent with the patient’s presentation. Therefore, it is a diagnostic reminder aiding the physician in performing a thorough examination. This alone makes it a desirable feature in an EHR system. As noted above, there are still legal problems with this software feature.

Conclusion

For the ophthalmology practice, productivity is enhanced by reducing clicks and footsteps along with organizing office visit types for the flow shop. Computer network configuration must be standardized and performance stabilized. Knowing this information helps obtain more structured details from software demonstrations. Structured details allow the ophthalmology practice to focus on the software features that enhance the flow of office visit types and foster efficient job shop productivity for the ophthalmologist. OM

Dan Salamie is a CPA with a masters degree in industrial engineering. He has devoted much of his consulting career to large-scale inventory management, such as with the VA, in addition to productivity issues with hospital pharmacies such as Grady Memorial. He finds that regardless of the problem, there are always computer issues that must be resolved before any productivity improvements can be accomplished. Semi-retired now, he is currently involved in startup companies engaged in vision related sciences. He can be reached at dsmail@att.net.