EMR: Now That I Have It, What Has It Done for Me?

Conclusion of a 5-part series.

RAYNOR CASEY, MD · ANDREW N. ANTOSZYK, MD

In preceding articles in this series, we have discussed whether you need an electronic medical records (EMR) system, when you might need it, how to choose a vendor, how the network infrastructure is designed and, most recently, how the installation of, and training for, EMR works. In this concluding article, we will discuss some of the lessons that have been learned.

EMR adopters have been in the trenches with the software every day. Was it worth the time and cost invested? Immediately after conversion, the EMR acronym alone may be enough to cause a low-grade migraine. Our conversion was difficult and the implementation as complicated as choosing a spouse. A limited survey of physicians and employees in both of our practices revealed varied attitudes about EMR adoption.

EMR FAQs

What do you think EMR has done for your practice? Overall, responses were positive and included improved and legible documentation and enhanced communications among physicians and employees. The quick availability of patients' records at any site and the improved ability of the business office to respond to insurance inquiries were frequently cited. Physicians particularly liked the ability to remotely access patient records when on call.

What are EMR's limitations? The most common complaint was the slow speed of the software, which many respondents felt slowed patient visits. There was an added delay if physicians wanted to sign charts while in the room with the patient.

What are the benefits of implementing EMR? EMR has permitted our practices to obtain a 1.5% bonus from Medicare thanks to the Physician Quality Reporting Initiative, better documentation, and the ability to have discussions easily inserted into charts. Physicians noted improved access and communications and better medicolegal and coding support.

How could you make it better? Responses included making the software faster and allowing e-mailing of images. Additionally, referral letters need to be automatically generated and designed to look more professional.

Would you still make the conversion knowing what you know now? Almost everyone said they would still convert.

Has it saved you time or money? Most physicians felt that EMR, with the maintenance fees for software support and upkeep of the network, provided no cost savings but that the improved access and the ability to automate some of the documentation may save time.

CHOICES IN EMR

Once you have selected an EMR system, additional choices need to be made such as selecting hardware (routers, switchers, backup systems, etc.), software (ongoing training, maintenance, updates), office visit templates, templates for each procedure (focal laser, panretinal photocoagulation, pneumatic, etc.), templates for each diagnostic study (B scan ultrasound, optical coherence tomography [OCT], fluorescein angiogram [FA], indocyanine green (ICG) angiography, autofluorescence, ultrasound biomicroscopy, electrophysiology, etc.) and, most importantly for referral-oriented retina docs, the template of consult letters. We have dreamed of not dictating for years. Many of us have spent hours after clinic trying to remember details of patient encounters earlier that day to put in consult letters. If only these letters could be compiled automatically with all the usual information. The good news is that these things are possible, but require diligence and flexibility as you negotiate what to include.

Many of us may have spent months or even years looking for the most versatile and flexible EMR software for our practices. This, unfortunately, is a recurring theme among purchasers of different systems. Several examples of our need for flexibility include the ability to change the templates after the original setup, the ability to interact with other devices directly (OCT, B scan, photos), and the ability of the EMR to work smoothly with pre-existing practice management software.

It cannot be overemphasized that prior to signing any agreements, all expectations should be clearly written out. Every user will want something that is important to him/her. For some people, every installation aspect will be an issue. Commonly cited requests have been easy viewing of old data and referral letters.

DATA POINTS

Some EMR programs have a button for "data points" that permit you to choose the data you want to review. With the advent of therapies that target vascular endothelial growth factor (VEGF), physicians have found it useful to have the chief complaint, best corrected visual acuity, intraocular pressure, macular findings, and OCT data and scans readily reviewable. Parts of the exam that are not pertinent to the decision-making process, such as anterior-segment findings (conjunctiva, cornea, etc.), are removed. The data is displayed in a columnar fashion, showing the last several visits, and the display is scrollable (Figure 1).

Figure 1. Screenshot of "Data Point View" from the EMR software created by Health Care Intranet Technologies, Inc. (HCIT, Owings Mills, MD). Users are able to view pertinent data from previous visits on a single screen.

A nice feature of many software packages is the ability to retrieve thumbnails of previous OCT scans, FAs, autofluorescence images, B scan images, and visual fields on the main exam screen or on a separate imaging screen (Figure 2). From this screen, you can select individual or multiple images and display them in a larger version (Figure 3). This option is particularly useful when you wish to compare images over time. Add-on software that enhances your ability to easily review FAs, ICGs and color photos is also available, but you need to be sure that the software accommodates all types of equipment and is not proprietary to a single vendor.

Figure 2. Medflow software (Medflow, Charlotte, NC) screenshot of a thumbnail display of images in a patient's chart that can be viewed individually or in various layouts that allows physicians to perform side-by-side comparisons.

Figure 3. Display options that can be viewed from the Medflow software thumbnail screen, which provides side-by-side or 4-up displays that clinicians can use to simultaneously view various types of images. Similar types of images, such as OCTs from different dates can also viewed in these displays.

Easy retrieval of images allows physicians to demonstrate to patients their own pathology and response to treatment. Patients love seeing their before-and-after OCTs for macular holes, diabetic macular edema, central serous retinopathy, epiretinal membranes, and their macular architecture following anti-VEGF therapy. It is especially helpful when vision has not returned to meet the patient's expectation, yet the clinician can show a perfectly contoured macula where there used to be a gaping hole or 3+ macular edema.

REFERRAL LETTERS

Creation of referral letters is a major issue. Frequently, clinicians are told that the templates are easy to change and can look however they want. In fact, the templates are not always easy to change and seldom look exactly the way one wants.

Most templates will start out with the usual "Dear Doctor Doe," and the system automatically populates their name and address and then states, "I had the pleasure of seeing Jane Doe, a 55-year-old female, for a vitreoretinal examination on such-and-such a date." Then the software fills in the encounter data in a templated fashion.

It includes all the testing and procedures performed. There are also OCT and FA results. But the template does not really read exactly the way you would like, so you have to either dictate an addendum, type it in yourself, or have a secretary do it. You can fax the note from the exam room and have a cover letter that highlights the pertinent findings, but this requires a secretary and can take several minutes to do. Or you can dictate a cover page and have the note faxed with the dictated note, which can be done remotely. This may add 10 to 30 seconds onto a visit.

In creating the referral letter, some programs will allow you to add OCTs, photos or drawings to the letter, which is a nice touch, particularly if done in color. Another great feature of EMR which helps save time yet meets coding guidelines is the ability to immediately e-mail referring doctors a note requesting a review of the consultation note.

GROWING PAINS

One quickly learns that from a monetary standpoint, the cost of EMR is a wash. The seller representatives will illustrate all your cost savings beforehand, but will leave out the extra expenses you did not previously have. For instance, money you used to spend on dictation is now spent on the maintenance agreements for software, which may or may not include updates, hardware upkeep and replacement, and information technology support. In addition, you frequently add additional services, such as automated appointment-reminder software.

A practice that has implemented EMR will notice savings in not having to file and retrieve charts for each appointment, phone call, billing, and pharmacy refill. It has been estimated that, for each patient seen, there are 2 additional calls and/or billing questions that would have required a chart to be pulled. So if you see 33 patients in a day, that can amount to 100 or more chart pulls and refiles. A fast paper-chart finder can find a chart in a minute or 2 for small offices and 3 to 5 minutes for a large office. So ultimately, one saves several employee hours per day in not looking for charts.

Another misconception is that EMR will make a practice "paperless." What seemed to be the paperless office promised is not really paperless. Often a paper sheet follows the patient from front desk to the techs to the exam lane to the FA room and back to the front desk. It is often easier for the front desk to make the 3-month appointment in the practice management (PM) system from your secretary by writing it on the paper rather than looking it up in EMR and returning to the PM system.

The EMR does talk to the PM system so that charges that entered into EMR flow over to the PM, but even though they speak the same language, it can be a different dialect. It is not uncommon that front desk and posters have to "clean up" the charges because the PM system does not like the way the EMR says "OU." For all those bilateral coding entries retina specialists perform for FAs, OCTs, and extended ophthalmoscopies, they have to go in and change it to right and left or use a 50 modifier. This only takes a minute to do — but this translates to 30 minutes for 30 patients.

CONCLUSION

The take-home message is to be sure the software you invest in addresses these issues. Our practices have been using EMR for 2 or more years and our practitioners cannot envision returning to paper. Some frustration arises, but like all healthy relationships, we find that open communication leads to better outcomes and understanding. We are moving forward with our provider and looking at new ventures such as setting up a Web site where we can post patient letters and photos for referring doctors to retrieve with the proper credentials and authorization codes. This will save money on postage while presenting data with full-color OCTs and photos (not widely available by fax). Our Web site currently provides a place for patients to download the practice info, past medical history, and HIPAA forms to fill out and bring to their visit. But this next-generation Web site can allow them to fill it out online and directly go into your system.

While we waited out the first decade to see when the winner would arrive, it turned out there is no winner, so go ahead and take the plunge with whatever you think fits your needs now. RP