The Hows and Whys of Electronic Health Records

Although 5 years have passed since he and his two partners switched to electronic health records (EHRs), James Silone, DO, still remembers some of the inconveniences they encountered at the outset. At least two weekends each month, he had to drive to the office (a 30-minute round trip), located just outside Columbus, Ohio, to look up a patient’s chart, especially if he was covering for his partners or if an elderly cataract patient had difficulty remembering his or her medications. Also, the practice had to hire an employee whose sole responsibility was to pull charts for the next day’s patients—a 4- to 5-hour task.

With EHRs, Dr. Silone can now pull up a patient’s chart from any location inside or outside the office, including his home computer and cell phone. The employee who once gathered the charts now scans documents to send to referring physicians and makes sure that all report letters are faxed to physicians after a consultation. Additionally, Dr. Silone says that EHRs have improved his practice’s delivery of clinical care.

Can EHRs work for you as well? This article examines how EHRs might benefit your practice and offers some pearls for making the switch.

EHRS DEFINED
An EHR is a repository for all of a patient’s health information, including documentation from different health care providers and payment information.

EHRs are not the same as electronic medical records. “An electronic medical record is controlled by the provider,” notes Kevin Corcoran, president of Corcoran Consulting Group (San Bernadino, CA), who has lectured extensively on EHRs. “It is a document that describes how the provider has rendered care, and the patient has limited access,” he says.

According to Mr. Corcoran, EHRs offer

• Universal access in which the patient, health care providers, and payers can all view the same record. “Basically it provides transparency of the medical record,” Mr. Corcoran explains.
• Point-of-care clinical delivery support, in which patients can view their EHRs to see information that might help them manage their conditions. For example, a patient with diabetes might learn about the importance of monitoring his or her blood sugar, exercising regularly, and watching his or her diet. “Support for patients to take care of themselves is in EHRs,” he says.
• Patient-centric care and delivery methods, in which the EHR integrates all data in one place. That means a doctor can see what other providers have done and how they are taking care of the patient. In the example of a diabetic patient, these providers would include the patient’s general practitioner, endocrinologist, and ophthalmologist.
• Data analysis, in which EHRs let you analyze patients’ data to determine whether the treatment plan is working.

SLOW TO ADAPT
Despite the aforementioned advantages, many ophthalmologists remain hesitant to implement EHRs in their practices. Consider the following. A study published in 2008 by the American Academy of Ophthalmology found that, of 3,800 randomly selected members, only 12% had EHR systems in place, and just 7% percent were in the process of implementing them. Another 10% of members polled said they planned to transition to EHRs within 12 months.¹

The EHR adoption rate among ophthalmologists is similar to that of other medical specialists in the United States, with 13% to 15% of physicians already having EHRs, according to the AAO report.¹ In contrast, EHRs are nearly universal in Europe and the United Kingdom.

The AAO survey’s respondents cited high initial investments of money and time to select and implement an EHR system as the main barriers to adoption. To address this problem, the US government created the Health Information Technology for Economic and Clinical Health, or HITECH, Act. As part of the American Reinvestment and Recovery Act, the HITECH Act established programs under Medicare and Medicaid to provide incentive payments for the “meaningful use” of certified EHR technology. Those physicians who fail to switch to EHRs by 2016, however, will be penalized in the form of lower reimbursements. (For more on the HITECH Act, see the article “New Government Regulations in EHR: Be Ready” on page 64.)

OTHER MOTIVATIONS
Although the financial bonus provided by the government can help defray the initial costs, it should not be your sole motivation for switching to EHRs. “The time and investment far exceed the HITECH bonus,” Mr. Corcoran says.

The real payoff in adopting EHRs is the ability to e-prescribe, keep track of medications and allergies, and automatically generate the appropriate codes for billing Medicare and other third parties. In the long term, using the technology can save practices money by not requiring office space for storing paper charts, allowing doctors to stop using scribes, and reducing the time spent on dictation and transcription, for example.

“It’s just a better and more efficient way to practice medicine,” says Mary Ann Fitzhugh, vice president of marketing for EHR provider Compulink Advantage (Compulink Business Systems, Inc., Westlake Village, CA).

Perhaps the biggest advantage of EHRs is the time they save. “Recording patient data in paper charts is laborintensive and inefficient,” adds Charlie Jarvis, vice president at NextGen Healthcare (Atlanta, GA), another provider of EHR systems. “Valuable time and resources are consumed by completing routine exams, generating lens and medication prescriptions, sending out referral letters and pulling charts for simple telephone call triage. Multi-location practices in particular spend countless hours transferring paper records from one location to another and then even more time faxing follow-up information.”

In contrast, Mr. Jarvis says, EHRs reduce the time needed to capture data from diagnostic screening devices and integrate diagnostic test results into a single, paperless system.

The practitioners surveyed by the AAO who have EHRs tend to agree. Of those practices, 64% reported increased or stable productivity; 51% reported decreased or stable overall costs. They rated improved care of patients and billing/charge collection as the most valuable features.¹

Dr. Silone says that EHRs have allowed his practice to enhance patients’ care. For example, when managing glaucoma patients, he can review all the data, such as IOP measurements and visual fields, from previous examinations on one screen. This makes it easier for him to monitor these individuals for disease progression. He and his partners also use the system to let patients view educational videos about cataract and refractive surgery, including their personal postoperative treatment regimen. “It’s very nice, because a lot of [things] that we used to have to manually do is now done automatically,” he says.

CHOOSING A SYSTEM
Following are some pearls for implementing an EHR system in your practice.

Do Your Homework
Joseph L. Sokol, MD, a private practitioner in Shelton, Connecticut, who transitioned to EHRs, recommends getting advice from colleagues who use the technology. In a white paper created for Compulink, he also suggests going to trade shows to see multiple systems at once, getting demo disks to try the software at home, arranging for onsite visits, and visiting similar practices that use the system under consideration. Also, look for a system that is eye care specific and that is customizable.²

When Dr. Silone and his colleagues first considered converting to EHRs, they visited several vendors at the AAO’s annual meeting and found systems they liked. Next, they narrowed the list down according to cost and invited vendors to give live demonstrations at their practice. During these demonstrations, Dr. Silone, an office administrator, and a technician from the practice’s front desk could evaluate the pros and cons of each system.

Dr. Silone’s team had two specific requirements. First, the EHR software had to work with their practice management software so that no data would be lost when going from the clinical examination and diagnosis to billing. Second, they wanted the ability to customize the data. “We wanted to make sure all the menu systems had the terminology we were already using,” Dr. Silone says.

Understand the Costs
The cost depends on several factors, including the size of your practice, the number of locations, and the size of your staff, Ms. Fitzhugh says. Other factors are the software and whether your practice will need to purchase additional hardware (workstations, server upgrades, etc.) and interfaces to its ophthalmic equipment.

“It also depends on the route the practice chooses to go—an on-premise solution or a Web-based hosted solution,” she adds. “This will affect how much local IT support they need to plan for and will impact their cost.”

Get the Incentive
Make sure the system you choose will qualify for the incentive offered under the HITECH Act. This is especially challenging, however, as no one company is certified. An interim final rule regarding meaningful use was just released, but nothing has been finalized.

Mr. Jarvis suggests, “Look for vendors that offer a guarantee on their EHR and have a good track record of clients’ achieving milestones similar to the criteria for meaningful use reimbursements. Ophthalmologists want to find a real partner in this process—not just a vendor.”

In the meantime, consider whether the company goes through any type of certification program. For example, Ms. Fitzhugh says, “Compulink has obtained certification through the Certification for Health Information Technology. The Certification for Health Information Technology Certified 2011 Comprehensive program involves a rigorous, multifaceted evaluation of integrated EHR functionality, interoperability, and security. In addition, certified products meet or exceed applicable proposed Federal certification under the HITECH Act.

Ensure Integration
Make sure your practice can integrate the EHR software with its current diagnostic technology. The goal is to be able to integrate data into the patient’s record quickly and accurately.

“Much of the data documenting eye care patients’ current status are captured in ophthalmic equipment manufactured by a variety of different companies and using different electronic formats,” Mr. Jarvis says. “Integrating these data, which can include hundreds of data points, into patient records presents a daunting challenge. Manually rekeying this information is not only excessively time consuming, but [it] presents many opportunities for error. When looking for an EHR, look for one that simplifies this data integration.

Plan Ahead and Allow Adequate Time for Training
Dr. Sokol suggests developing a written plan that encompasses the patient’s initial phone call, the entire examination through checkout, and scheduling of follow-up examinations. The plan should include what information to enter when a patient first calls, who enters the history, where computers and printers will be located, what information will appear on the summary screen, and who should have which permissions. It should also consider whether the doctor or a scribe should enter data.

One common mistake practitioners make is not allowing enough time for training. “People really need to go through practice sessions,” Ms. Fitzhugh says. “Training needs to start in advance.”

Dr. Silone had someone come to the office for a week to work with each of the three groups in the practice: physicians, technical staff, and billing staff. During the training, initial templates for entering examination data were set up, and the team performed mock examinations to practice using the system.

Do Not Try to Do Too Much at Once
“The goal should be to implement smoothly without letting EHR take over your life,” Dr. Sokol says.

The conversion to EHRs can take anywhere from 8 weeks to several months, possibly longer, depending on how many users there are and how many practices they have, Ms. Fitzhugh adds.

Some practices attempt to scan all of their paper charts only to realize this approach may not be efficient. A more effective approach, Ms. Fitzhugh says, is to start the EHR at the patient’s next visit. Also consider phasing in the conversion.

Dr. Silone’s practice chose a date to go live and, from that point on, stopped using paper charts. They initially scheduled 20% to 25% fewer appointments and had an employee enter demographic history and pertinent medical information prior to the patient’s appointment. As they preloaded more data, they were able to increase their patient load.

Implement a Disaster Recovery Plan
“[Practitioners] need to make sure they are doing backups,” Ms. Fitzhugh stresses. “This is not just losing your patient schedule; this is losing all your patient records.

Dr. Silone’s practice backs up the entire system each night. “We have several of these hard drive backups,” he says. “We keep one off site, one in a firebox in our office, and one hooked up to the server. Therefore we always have a backup that we can use.”

Individual vendors may also have a dedicated site for backing up data.

CONCLUSION
EHRs offer many possible benefits to a practice beyond the incentives of the HITECH Act. These include greater efficiency, improved clinical care, cost savings, and, in Dr. Silone’s case, at least an extra half-hour to himself on weekends.

Kevin Corcoran may be reached at (800) 399-6565; kcorcoran@corcoranccg.com.

Mary Ann Fitzhugh may be reached at (800) 456-4522, ext. 236; maf@compulinkadvantage.com.

Charlie Jarvis may be reached by contacting Kristy DelMuto at (215) 657-7010, ext. 1788; kdelmuto@nextgen.com.

James Silone Jr, DO, acknowledged no financial interest in the companies or products mentioned herein. Dr. Silone may be reached at (740) 522-8555; silone@centerforsight.com.

Joseph L. Sokol, MD, acknowledged no financial interest in the companies or products mentioned herein. Dr. Sokol may be reached at (203) 926-1700; jsokol@ctispec.com.

1. Chiang MF,Boland MV,Margolis JW,et al.Adoption and perceptions of electronic health record systems by ophthalmologists:an American Academy of Ophthalmology survey.Ophthalmology.2008;115(9):1591-1597.
2. Sokol JL.Strategies for transitioning today’s ophthalmic practice.Electronic Health Records (EHR).Westlake Village,CA : Compulink Business Systems;2009.