By Rishi P. Singh, MD, Cleveland Clinic Cole Eye Institute vitreoretinal surgeon

Like it or not, electronic medical record (EMR) systems are slated to become commonplace in ophthalmology over the next few years, regardless of practice setting, geographic location and subspecialty focus. Our field in particular faces significant obstacles to widespread adoption, based on the unique features of its practice.

For example, in just the management of age-related macular degeneration, monthly patient visits are commonplace and result in the accumulation of large amounts of diagnostic and procedural documentation over the lifetime of the patient. In addition, ophthalmologists are used to manual entry methods such as hand drawings of pathology, which is poorly emulated in current EMR systems.

These obstacles and others are the reasons why adoption of EMR systems has been poor. In 2006, the American Academy of Ophthalmology’s (AAOs) survey of its members found a 12 percent adoption rate, compared with a 17 percent adoption rate for physicians across all other medical specialties.

Patients have now come to expect information on demand, which EMR systems allow. This ready access to their records has enabled patients to become better partners in their care.

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A reason often given for not adopting EMR is the cost of implementing the system. Health Information Technology for Economic and Clinical Health’s $27 billion grant might help offset some of these costs, but there is no textbook or preferred practice pattern on beginning this process. At Cleveland Clinic, we have successfully implemented an EMR system within our practice. This discussion will focus on details of the process, such as identifying essential functions to look for in vendor products and tips on implementation.

Both sides of the coin: pros and cons of adoption

The addition of EMR has some significant advantages:

• Thorough, secure documentation: Level of compliance with time stamps, procedure documentation and security measures increases greatly with EMR. Most EMR systems have predefined documentation for common ophthalmic procedures, and it’s important when evaluating the system to compare these to your local carrier or CMS guidelines to see if they match up. When under the scrutiny of an audit, the EMR system can be a lifesaver.
• Easy adjustment and modification: Many EMR systems allow for the documentation of normal values for the specific eye fields, and components can be globally modified with a keystroke. For example, when an audit showed another practice lacked a particular exam component, we could implement a change in the EMR template within a day.
• Remote access: Having the records available anywhere and anytime really helps with patient care. According to the AAO, 45 percent of ophthalmologists work in multiple offices; when EMR is in place, patient care is informed and updated regardless of location.
• Storage cost savings: Medical record storage costs decline considerably with EMR.
• Complete overview of patient data points: Integrating values such as intraocular pressure, corneal thickness and other quantitative measurements, the EMR permits trending of patients over time, allowing for a much more comprehensive evaluation of disease progression.
• Determination of practice efficiencies and pitfalls: We can allocate clinic resources such as space and tech coverage based on reports on previous technician and clinic performances. Our system has been able to drill down to determine how long technicians take to work up patients and how long a procedure or diagnostic procedure takes to perform.

But with as many advantages as EMR offers, there is a balance of significant drawbacks.

• Technology costs: Whatever you think you will save by converting from paper charts (storage fees, personnel for records management) will be offset by information technology maintenance, high-speed Internet lines and electronic backup and storage.
• Software delays and frustrations: Expect monthly or yearly software upgrades with the expected bugs, annoyances and potential downtime.
• Data entry demands: Keystroke entry is virtually universal so you must be a proficient typist. The temporary decrease in efficiency and lost revenue on the initial implementation are sometimes too much for practices to bear.

Choosing the right system for you

Consider these key factors when deciding what type of system is best suited to your practice.

• Government certification: Make sure that you are receiving a government-certified product.
• Individual or shared system: Consider whether to partner up or go it alone. Local hospital systems may offer usage of their EMR for a nominal charge, but few have ophthalmic-ready systems. A better option might be to share the cost of the IT system or bargain collectively with another nearby practice when dealing with the EMR vendors.
• Customization needs: When evaluating a system, determine the level of customization needed. Does the EMR mimic your workflow or practice pattern? Do the items within the EMR represent all the specialties within your practice? Some EMRs are specialty-specific even within ophthalmology.
• Firsthand view: Visit your colleagues who have successfully implemented a system to understand what their real experience has been. We visited many sites prior to finalizing our choice to seek out the features and functions that we wanted to implement within our own system.

Putting your system to work

Choosing the right system is only half the job. Implementation can make or break your conversion.

• Assemble a complete team: Assembling a multidisciplinary team composed of a physician, technician, biller/coder and administrator is a good first step. Walking through the EMR workflow with this team can help in troubleshooting early problems.
• Choose a slow time of year: Consider choosing a lower-volume time of year to make the switch to reduce the economic impact of the implementation process. We chose to down-book by 25 percent for the two-week duration of the go-live in order to give our physicians adequate time to acquaint themselves with the system.
• Plan the rollout: By bringing the clinical volume back to normal levels quickly, we found that many physicians began to employ workflow efficiencies in order to keep pace. When considering big-bang rollouts versus gradual implementations, we chose a more gradual approach that allowed us to troubleshoot the workflow, off-load patients to another provider and train technicians by rotating them through the clinic prior to their go-live.
• Use scribes in transition: Scribes are an important consideration for any practice. Every study performed has shown that the utility of scribes decreases significantly as the practice becomes more familiar with the EMR system. Thus, we chose to hire additional technicians to serve as physician extenders within the clinic.

Conclusions

With all the pitfalls and efforts needed to navigate the process, why would practices choose to go forward? Having three years of experience using Cleveland Clinic’s EMR system has taught me how invaluable it can be. Patient calls can be answered quickly and efficiently. I’m communicating more than ever with referring and primary care physicians. I can perform chart reviews and clinical research studies within days and not weeks. Lastly, patients have now come to expect information on demand, which EMR systems allow. This ready access to their records has enabled patients to become better partners in their care.