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Cover Stories | Jun 2012

Pearls for Implementing an EHR System

The key is finding one that fits your practice's needs and workflow.

My practice, which includes two ophthalmologists, one optometrist, and four opticians, has been paperless for more than 12 years. Only in the past 5 years, however, have we converted to a true electronic health record (EHR) system and qualified for all of the government's incentive programs. After the first quarter of 2012, we will qualify for meaningful use, an endpoint designed by the government to demonstrate that providers are positively affecting patients' outcomes with an EHR. There are three phases of meaningful use, and we are presently in phase one. Currently, practices can attest to meaningful use on a website and file for funds.

Do not be tempted to attest incorrectly, because on this issue, the government reviews records as far as 10 years back. We opted not to apply for meaningful use in 2011 to maximize our returns on the other incentive programs.

Software salespeople are very talented at selling. Implementation is another story, and this article shares pearls from my experience.


Leadership by the practicing physicians is the single most significant factor in implementing an EHR system. If the practicing physicians do not play an active role in the implementation phase, success is doubtful. Your administrator may be able to do a great deal of the groundwork, but does he or she really understand how you work? Is he or she in the room with you and/or your scribe? You need to decide who will enter what information into the record regarding patients' visits. Who will do the billing, and how will he or she match the codes to the correct diagnosis?

In my practice, the physician enters the diagnosis and the billing codes. He or she checks that the two codes are appropriately matched, and when he or she signs off on the chart, the billing information automatically passes through the interface and is in the practice management system before the patient reaches the front desk to check out. A well-trained scribe can also enter the codes. A data entry clerk is not required, because superbills are not used.

Prescriptions are handled the same way. Once the patient's record is closed, it is automatically sent to his or her pharmacy via the built-in e-prescribing system. We write virtually no paper prescriptions, and the EHR system generates and faxes letters to consultants and primary care doctors at the end of the patient's visit, which eliminates dictation fees. In the future, faxing will be eliminated as other physicians adopt systems that can accept our electronic reports. Visual field tests, corneal topography, optical coherence tomography, specular microscopy, photographs, IOLMaster readings (Carl Zeiss Meditec, Inc.), and Holladay 2 IOL calculations (Holladay IOL Consultant; Holladay Consulting Inc.) are generated by the respective devices and attached to the patient's chart. A paper copy is not produced. This works well, but was it easy to get from paper to this? Not even a little!


The staff will know if the physicians are dragging their feet throughout the transition from paper to digital. If the physicians are not the driver for the conversion and are instead coerced into it by a wellmeaning administrator, the staff will feel the same way. Do not be fooled. Adopting an EHR system is a significant change for the practice. The physicians must pull the cart, not be pulled along by it. This means that they must be willing to go through the training and make the transition. The owner(s) of the practice must be the driving force.


Most vendors will claim that data are portable to any other system with their EHR software. Having gone through this process three times in 12 years, I can tell you that data never populate the new system the way you want it to. There is always a compromise, so do your homework. See other practices that are similar to yours, and pay attention to the pros and cons of the software that is being used.

In terms of vendors, think about whether the company you are considering will still exist in 5 years to continue to support your product. Small startup companies are responsive and innovative, but will they survive the consolidation that is surely coming? Questions regarding wired or wireless, fixed terminals, mobile devices such as iPads (Apple, Inc.) or laptops, and running a thick client or terminal services are all decisions that need to be resolved. The practice's workflow is what should drive decisions.


After you choose a vendor, implementation is the next phase. Training will probably cost as much or more than the software and hardware. Divide training costs into two phases, with the first's being the actual cash paid to the vendor for its trainer(s) to work with you and your staff. Even though I wrote the content and the workflow for the solution at my practice, I still hired trainers to spend time with my staff. The cost was reduced, because I streamlined the process.

The second cost of training is the time your staff will spend on activities that do not produce revenue. Not only do you have to pay your staff for training, but when the system goes live, do not expect to work at the same pace as prior to implementing EHRs. There will be a period of time to ramp up to full speed and, one hopes, achieve better results than before the EHRs' implementation. In my practice, we cut our patient volume to 50% for the first week and gradually ramped back up. It took a month until we were achieving our preimplementation numbers and another month to exceed those numbers.


It may be helpful to activate the EHR system in phases. I recommend beginning with the output from various technologies and the e-prescribing system. This will help the staff become familiar with using the system. Next, implement the intraoffice e-mail; this will increase the staff's use of the system. Lastly, enter patients' examinations.

Although it is a challenge to implement an EHR system, one that fits your practice's needs and workflow will save time and money and allow you to be a much more efficient practitioner.

Richard G. Davis, MD, is the founder of Precision Eye Care in Huntington, New York, and a surgeon at Island Eye Surgicenter in Long Island, New York. He acknowledged no financial interest in the products or companies mentioned herein. Dr. Davis may be reached at (631) 462-2020; eyeguy@precision-eyecare.com.

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