Do I Need EMR and When Do I Need It?

Part 1 of a 5-part series.

RANDY DHALIWAL, MD, FRCSC, FACS • OKSANA M. DEMEDIUK, MD, FACS • ANDREW N. ANTOSZYK, MD

The past decade has seen many changes in the practice of retinal physicians. More practices have multiple offices and can access patient data and deliver information. Additionally, the need to reduce errors associated with getting wrong information has become more important. Not only have there been changes in the pattern of clinical care with new pharmacological options for neovascular conditions, but physicians have seen declining reimbursements for surgical interventions relative to cognitive services.

There has also been an increase in documentation requirements by government and private payers, a preference for electronic billing over paper submissions, Health Insurance Portability and Accountability Act regulations, Pay for Performance proposals, and the Physician Quality Reporting Initiative. These changes have forced clinicians to become more engaged in practice management issues.

Compounding the administrative headaches of clinical practice is an increasing population of patients in need of retinal services. By the year 2030, the population of individuals over 65 will have most likely doubled from the turn of this century. This has increased the pressure on each practice to be ever more efficient to cope with this surge and still meet all the regulatory needs placed upon clinicians.

THE INITIAL PUSH

In the spring of 2004, President Bush articulated a vision calling for interoperable Electronic Health Records (EHR) for most Americans by 2014 and appointed a National Coordinator for Health Information Technology. The President then increased the budget to implement this vision to $125 million by 2006. Indeed, the perceived need for universal Electronic Medical Records (EMR) has been touted by all the current presidential candidates, both Republican and Democrat, as a means of saving money and reducing medical errors. The CMS has also suggested giving financial bonuses to those providers using EMRs.

Expanded screen shot views of how an electronic health record can organize data and images from multiple sources for review.

Although EMR implementation has been touted for over a decade as vital to retinal practices, the adoption rate has ben low in the United States. Among the countries making progress in EHRs are Germany, New Zealand, and Canada, all of which have some national government ownership of the initiative. The US government is involved in the financing of health care (eg, Medicare) and in the delivery of care (eg, the Veterans Health Administration), but the regulation and credentialing of healthcare professionals is a state function. Furthermore, the US healthcare sector is very much under private control.

The slow US adoption rate of EHRs is also related to a lack of funding to develop software that intuitively works as retinal physicians do, poor image management tools, high cost of equipment, and a general reluctance by established physicians to give up patterns of practice flow with paper appointment schedules, ledger cards, and paper claims submissions. As the ubiquity of the EHR rises and the costs to install and use decrease, it can be anticipated that the EHR will become widely used by all physicians.

PROGRESS IN INTEGRATION

Electronic Practice Management (EPM) software now makes it possible to meet the accountability and compliance requirements of clinical charting, which government and private payors are demanding, through automation. These advances also allow streamlining of scheduling and claims submissions while also providing powerful tools to analyze the clinical and financial aspects of the practice. Moreover, a new generation of ophthalmologists has arrived on the scene who are very comfortable utilizing this new information technology as a tool to work more efficiently. The evidence is clear that the time to transition to an EMR in retinal practice is now at hand. The extent of the system a practice adopts should take into consideration its size, composition, and needs.

WHAT IS AN EMR?

An EMR is more than a word processor for generating letters and fulfilling charting requirements. An EMR is a relational database that stores discrete data elements that become infinitely searchable. The EMR is a system that collects data from multiple sources and then makes that data available at the point of care. In retinal practices, this should ideally include access to and archiving of all imaging modalities to allow ready review from any location in real time.

When choosing an EMR, it is important to ask whether the program is written in "open source code" that allows for individual preference-directed changes that are vendor independent. The ideal EMR should be based on a nonproprietary database such as My-SQL (to protect the practice from loss of vendor support), which should be capable of limitless record storage (as image archiving consumes a great deal of storage space).

To be most effective, the EMR must integrate with an EPM system for scheduling, billing submissions, letter and report transmittals, consenting for procedures, business and financial reporting, and transmission of data through the Internet. There must be full connectivity between the EMR and EPM systems and ideally they should be written by the same software provider. If a practice has a pre-existing EPM, then it is important to ask whether the EMR company has an interferace to permit communication between their EMR and the practice's EPM program.

WHAT DETERMINES SUCCESSFUL ADOPTION?

Key to successful adoption of an EMR/EPM system is careful research of the various vendors in order to find an application that works most like your current practice. It is very important to perform multiple on-site visits to successful working sites for the EMR/EPM of interest and also to seek out those practices that had failed installations with the vendor of interest. It is important that technicians and clinicians are comfortable with data entry and flow. The vendor should be experienced and flexible to the changes your practice might require and provide ready support.

Commitment to making the transition to an EMR/EPM system is of prime importance to the success of integrating it into a practice. All physicians in the practice must switch to the EMR and realistic goals must be made and kept. A phased transition to the EMR/EPM system (implementing the billing and financial reporting modules last) allows the staff to become familiar with the software and reduces negative effects on clinical and cash flow.

The largest impediment in adopting an EMR/EPM system is the financial outlay required to implement the process. It is prudent to hire a hardware vendor that is not affiliated with the EMR vendor to provide guidance on designing the network, not only for the present but foranticipated growth. Using separate vendors is important as the need for regular hardware and network support is inevitable. Preferably, one should select a local hardware vendor so that network issues can be dealt with expeditiously. The cost of hardware can vary from $10,000 to $75,000 per physician, depending on preferences. The EMR/EPM software system should cost between $5,000 to $50,000 per physician, depending on preferences and number of offices.

WHAT IMPACT SHOULD WE SEE?

After an initial slowdown in productivity while installing the software system and training staff, there is generally an improvement in the productivity to normal levels within several months. The improved documentation allows physicians the flexablity of confirming that they have the appropriate documentation for the billing codes they select. The patients are generally appreciative of the "state-of-the-art" technologies and this appreciation will allow for increased face-to-face time with the patients. For group practices, the EMR system will standardize documentation amongst all physicians while also creating more thorough documentation.

The EMR should provide the ability to reduce repetitive tasks associated with charting and automatically generate disease condition-specific consents, orders, patient instructions and information materials, letters, and other routine tasks. It should also allow immediate access to imaging modalities from any room or office in real time.

The benefits of successful adoption of an EMR/EPM system also extend to simpler insurance carrier audits and more accurate coding and records that are more difficult to fault by litigious attorneys. The EMR will also allow the practice to readily identify noncompliant patients and document this in the clinical record.

The fully implemented EMR/EPM system will allow a practice to track patient referral patterns. The EMR can provide automated generation of letters and reports that can be sent by facsimile to the referring source before the patient even leaves the office. This also translates into reduced transcription costs and the need for scribes.

The detailed financial and productivity reports that an integrated EMR/EPM system can provide are invaluable in tracking practice patterns over intervals of time and reimbursements between individual physicians in the practice. The immediacy of access to patient information from home or office also provides the ability to reduce patient-care errors and provide better quality care at any time.

CONCLUSION

Why an EMR? The EMR/EPM system will allow clinicians to demonstrate and document the quality and performance of care provided in their retinal practice. A successfully implemented system should allow a practice to get control of its financial present and future and ultimately result in increased free time for clinicians. RP