What I’ve learned during my time in the EHR trenches.

Over the course of my career, I have used seven different EHRs, five different image management systems, and have overseen the installation of two EHRs and three image management systems.

As director of information technology at the Johns Hopkins Wilmer Eye Institute, for most of the past decade I have been responsible for the deployment and maintenance of clinical information systems for a large academic ophthalmology practice with more than 100 physicians at eight geographically disparate locations. My experiences have led me to develop some concepts that I believe have been critical to keeping our practice running in the face of wholesale changes in our documentation of patient information.

FIRST EDICT

If there is one over-riding concept that I would want every ophthalmology practice to internalize, it is that you must exert control over your information systems or they will exert control over you. Just as you would not move your practice into a new physical space without being intimately involved in the design of that space, neither should you fundamentally change how your practice operates using information systems without ensuring that those systems reflect how your practice operates (or, even better, how you wish it to operate).

GET DEVICES AND SYSTEMS ON SPEAKING TERMS

Information systems in a typical ophthalmology practice fall into four common areas: registration and scheduling, claims and billing, clinical documentation (EHR) and image management. Because the first two were easier to integrate into clinical practice and provided clear efficiency gains, many practices had computerized those aspects well in advance of any “meaningful use” incentives, leaving clinical documentation and image management on paper. It is therefore common for a given practice to have multiple IT system vendors, each providing one or more of these functions.

To maximize your practice efficiency, it is essential that any and all clinical IT systems be integrated so that they share patient demographics. Without such links, it is impossible to ensure that patient information in one system is consistent with all others. All it takes is a mistyped medical record number or date of birth, and those two systems can no longer know that the data belong to a single patient.

Just as your clinical information systems should be integrated, so too should your in-office testing devices be tied together using the DICOM standard. This enables you to share patient demographics with your devices, again avoiding the issue of mistyped name and numbers preventing you from linking test results to the corresponding patient in your EHR and billing systems.

Beyond the inefficiency of having to reconcile “missing” patient images during clinic, there is the issue of patient safety. It is critical to have all of a given patient’s information in one place at the time it is needed to make diagnosis and treatment decisions.

TAKE ADVANTAGE OF WHAT YOUR EHR DOES WELL

Strange but true: the fact that EHRs are computer based should be viewed as an advantage, not as an obstacle to overcome. Given that my job is fundamentally about translating the needs of the clinician into solutions that computers are better able to address, I have started a list of concepts that can help a practice make better use of its EHR.

1. Make sure you and your staff document data in only one place for each patient. For example, don’t type the medication list into the HPI and then reconcile the medications in the “real” medication list. Double data entry is fundamentally inefficient; avoid it whenever possible.
2. Take advantage of the fact that computers are good at displaying information to summarize a patient over time so that you don’t have to flip through old notes to find a two-year-old IOP right before surgery. This might include some combination of graphs, tables, problem-based summaries, key images, visual representations of procedures in relation to exam findings, and so on.
3. A third principle follows from the first two: computers can help you display the same source data (history, exam, plan) in different ways for different audiences. You may have one way of displaying the information collected as part of an encounter for internal review, another way of organizing that same information for generating a letter to the referring provider, and both can be derived from the same data you entered once.

CUSTOMIZE DESIGN AND TRAINING

Getting initial buy-in and convincing all members of your practice that computerized workflow can indeed make their practice run better is one of the greatest challenges you will face. If there is any chance for this endeavor to succeed, clinician input into the design and implementation of the systems is essential. Many practices make the mistake of leaving this up to the system vendor — then end up suffering the consequences.

Beyond that, it is also critical to design the training to focus on how the system will actually be used in clinic so that the users have some hope of understanding why learning about the system is important. There is not one method by which all physicians and staff will be engaged, so you will have to determine the right combination of methods for your staff: these include in-person training, e-mail updates, creating a central repository of tips for using the system, one-on-one personalization and posting go-live retraining.

Whether you have a large academic practice or a one-provider operation, it is important to know that success with an EHR is possible. While I have found no magic formula (if you know of one, please share!), the principles above should help you get closer to the goal of making your practice the best version of its electronic self. OM

Michael V. Boland, MD, PhD, is associate professor, Wilmer Eye Institute and Health Sciences Informatics, and director of Information Technology, Wilmer Eye Institute, Johns Hopkins University School of Medicine. Additionally, he serves as co-chair of the American Academy of Ophthalmology’s Medical Information Technology committee. Contact him at boland@jhu.edu.