At Press Time

Study Redefines Potential of EHR

Earlier projections of savings were too optimistic, study suggests.

By René Luthe, Senior Associate Editor

■ In 2005, an influential report by the RAND Corporation predicted that widespread implementation of electronic records could save the US health-care system approximately $18 billion a year. You know what happened next: The study was widely publicized and in 2009 the Obama administration and Congress authorized billions of dollars in federal stimulus money to help physicians and hospitals purchase health IT systems.

Ever since, practices have scrambled to buy information technology systems and qualify for subsidies and incentives. Nearly eight years after the report that started the fuss, RAND has issued another report on health information technology, this one published in Health Affairs. Its findings? The previous report may have overstated the benefits of EHR.

That said, the good news is the potential for widespread adoption of improved EHR technology still has the potential to generate significant cost savings for individual medical practices and the overall health-care system, the report finds.

EHR In the Real World

The new RAND report, authored by Arthur L. Kellermann and Spencer S. Jones, finds that instead of EHR reducing health-care expenditures, annual aggregate expenditures in the Unites States have actually grown — from approximately $2 trillion in 2005 to roughly $2.8 trillion today. Moreover, implementation of health-care IT has improved the quality and efficiency of patient care “only marginally.” The Congressional Budget Office criticized the 2005 Rand report for overstating the expected savings from EHR adoption.

The report says the failure of EHR systems to deliver on their promise is due to shortcomings in their design and implementation. “We believe the anticipated productivity gains of health IT are being hindered by the sluggish pace of adoption, the reluctance of many clinicians to invest the considerable time and effort required to master difficult-to-use technology, and the failure of many health-care systems to implement the process changes required to fully realize health IT’s potential,” the authors wrote.

Specific problems the report cited include the lack of interoperability between systems and difficulty in operating them, with health-care workers complaining the systems slow them down. Vendors’ rush to adopt existing EHR systems to qualify for limited-time incentives may have contributed to these shortcomings, the authors stated. “If market forces were allowed to work, doctors might drive vendors to produce more usable products … some experts fear that the federal government’s health IT incentive program might inadvertently exacerbate the problem by encouraging providers to purchase hard-to-use systems that will be costly to replace …”

Don’t Throw in the Towel

Christine M. Archibald, chief executive officer of Management Plus, a maker of ophthalmology-specific EHR software, isn’t surprised that EHRs haven’t lived up to their promise quite yet “The industry is investing in this technology, but there’s a point at which this will peak,” she explains. “Then the cost savings will start to come into play. This will be particularly true when physicians will be able to consult recorded data. For example, if a patient presents with conjunctivitis, and the doctor has to choose between prescribing medication A or medication B, data can show that medication A is less expensive but just as effective as B.”

If you’re practice has not yet purchased EHR, Ms. Archibald has some advice to help avoid buyer’s remorse: Closely review the templates the doctor would use for data entry. “That will give you a good idea of whether the vendor knows what they are doing,” she says. And the templates should already be built. Vendor promises of “we can build that entirely new for you” seldom work out to the buyer’s satisfaction, she notes. Other EHR problems, such as interoperability, will be worked out in time, she says. “It’s an evolving process.”

Kellermann A, Jones S. What it will take to achieve the as-yet-unfulfilled promises of health information technology. Health Affairs. 2013;32:63-68.

AAO Suggests Five ‘Best Practices’

The goal: Eliminate unnecessary and unproductive tests and treatments.

By Jerry Helzner, Senior Editor

■ In announcing its participation in the national, multi-specialty Choosing Wisely campaign, the American Academy of Ophthalmology is encouraging ophthalmologists to more fully discuss with their patients treatment options and more efficient use of health-care dollars. The Academy is now citing five specific tests and treatments that should be discussed so that patients will be more fully informed as to why certain tests and treatments may be unnecessary at best and carry some risk at worst.

Choosing Wisely is an initiative of the American Board of Internal Medicine Foundation that has enlisted 17 organizations representing more than 350,000 health-care professionals. The campaign’s goal is to have participating organizations develop lists of commonly performed tests, procedures and treatments that patients and physicians should discuss.

The Academy says it has identified the following five common tests and treatments that ophthalmologists and patients should discuss:

► Preoperative Medical Tests. Don’t perform preoperative medical tests — such as an electrocardiogram or blood glucose test — prior to eye surgery unless there are specific signs indicating a need for them.

► Imaging Tests. Don’t routinely order imaging tests when there are no symptoms or signs of significant eye disease.

► Antibiotics for Conjunctivitis. Don’t prescribe antibiotics for pink eye caused by an adenovirus.

► Antibiotics for Eye Injections. Don’t routinely provide antibiotics before or after injections into the vitreous cavity of the eye.

► Punctal Plugs for Dry Eye. Don’t treat dry eye by inserting punctal plugs before attempting other options, such as medical treatments with artificial tears, lubricants and compresses.

“Some experts estimate that up to 30% of health care delivered in the United States may be unnecessary or duplicative,” said Academy CEO David W. Parke II, MD. “Not only does this represent significant waste, but it also underscores patients’ unnecessary exposure to risks associated with any test or procedure.”

The Academy says it is participating in ChoosingWisely as a way to support evidence-based medicine and promote more patient involvement in their care. The Academy’s health policy committee led the development of the list of with input from members and ophthalmic subspecialty societies. Numerous recommendations and supporting evidence were researched and reviewed under the leadership of William L. Rich III,MD, medical director of health policy for the Academy.

“In medicine, more isn’t necessarily better,” Dr. Rich said. “Conversations around the five tests and treatments … can reduce the potential for over-treating our patients.We will continue our work to identify treatments that could benefit from better conversations between ophthalmologists and their patients.”

ASCRS Medication Alert for LASIK and PRK

Issues with additives; caution against preoperative and intraoperative use.

■ The ASCRS Cornea and Refractive Surgery Clinical Committees have issued a joint alert regarding the use of some topical medications immediately before or during LASIK and PRK.

Several new topical ophthalmic medications have become available that contain advanced vehicles designed to deliver consistent dosage of active ingredients, increase contact time on the eye, stabilize the ocular surface and reduce dosing frequency. These medications are not FDA-approved specifically for LASIK or PRK, but clinicians have commonly used them for these procedures. Several cases of flap slippage or diffuse lamellar keratitis, or both, following LASIK have been reported when topical ophthalmic medications with these advanced vehicles have been instilled immediately before LASIK or intraoperatively while the flap has been elevated.

No problems have been documented with the use of these medications after the flap has been properly positioned. However, cases have been documented of poor epithelial healing when topical agents with these advanced vehicles have been instilled on the stromal bed following PRK and before bandage contact lens placement.

ASCRS released the following list of medications included in the alert:

• Azithromycin 1% (Azasite, Merck) solution with polycarbophil, edetate disodium and sodium chloride.

• Besifloxacin 0.6% (Besivance, Bausch + Lomb) suspension with polycarbophil, edetate disodium and sodium chloride.

• Cyclosporine emulsion 0.05% (Restasis, Allergan) with castor oil.

• Difluprednate emulsion 0.05% (Durezol, Alcon) with castor oil.

• Ketorolac 0.45% (Acuvail, Allergan) solution with carboxymethylcellulose sodium.

• Loteprednol 0.5% (Lotemax Gel drop, Bausch + Lomb) gel with glycerin, polycarbophil, propylene glycol and tyloxapol.

• Moxifloxacin 0.5% (Moxeza, Alcon) solution with xanthan gum and tyloxapol.

• Nepafanac 0.3% (Nevanac, Alcon) suspension with mannitol, carbomer 974P, sodium chloride, tyloxapol and edetate disodium.

• Nepafanac 0.3% (Ilevro, Alcon) suspension with propylene glycol, carbomer 974P, guar gum and carboxymethylcellulose sodium.

Additionally, the ASCRS alert notes a number of highly viscous artificial tears and lubricating drops contain the same inactive ingredients and may pose similar hazards when used during LASIK and PRK. These medications contain vehicles that have the potential to be sequestered beneath a LASIK flap or a bandage contact lens following PRK and not absorbed, the alert concludes.

Dr. Peyman is Honored at White House

LASIK pioneer receives Technology and Innovation Medal.

■ Ophthalmologist Gholam A. Peyman, MD, a faculty member with the University Arizona College of Medicine-Phoenix, was one of 11 inventors to receive the National Medal of Technology and Innovation in aWhite House ceremony on February 1. Dr. Peyman has been credited as the primary inventor of LASIK surgery. The award is the nation’s highest honor for technological achievement.

“When Dr. Peyman first accepted a position at the University of Illinois, his office was a converted restroom, President Obama said in bestowing the award. “But he carved out enough space for himself, his secretary and his lab equipment and today he is known as the father of LASIK eye surgery.”

Dr. Peyman receives his medal from President Obama at the White House.

Dr. Peyman, a vitreoretinal surgeon and prodigious innovator, has more than 135 patents. His inventions cover a broad range of novel medical devices, intraocular drug delivery, surgical techniques, laser and optical instruments, as well as new methods of diagnosis and treatment. He has won numerous honors and awards, including being inducted into the Hall of Fame of Ophthalmology.

“I am so honored by this award,” said Dr. Peyman in a statement. “What a wonderful surprise. I am gratified that our work has touched so many people.We work always to enhance treatments and improve outcomes for patients.We continue to look forward since there are many more problems to solve.”