Like it or not, electronic medical record (EMR) systems have become commonplace in ophthalmology, regardless of practice setting, geographic location, and subspecialty focus. In the retina subspecialty in particular, there are significant obstacles to this transition based on the unique clinical workflow and data management features of these practices. For example, in the management of age-related macular degeneration (AMD), monthly visits are commonplace as is the acquisition of large amounts of imaging material over the lifetime of the patient. In addition, retina specialists are used to manual entry methods such has hand drawings of vitreoretinal pathology. Nearly 10 years after the $27 billion Health Information Technology for Economic and Clinical Health (HITECH) grant was approved by US Congress, this article examines whether the implementation of EMRs in retina practices has been as successful as retina specialists once thought it would be.
REDUCING COST AND INCREASING REVENUE
Debate continues over the potential of EMRs to reduce health care costs. Certainly, fixed costs such as medical record storage and transcription volume would fall. In addition, medical carriers require significant documentation to bill for procedures and office visits that were next to impossible to complete on paper, so clinicians anticipated that denied and lost charges would be reduced. Balancing these potential improvements in revenue are the fixed and ongoing fees for licensure of the EMR product and storage of the data on servers, which would continue indefinitely.
The Cleveland Clinic has implemented Epic Kaleidoscope, the ophthalmology module by Epic Systems. It allows ophthalmologists and optometrists to perform eye exams, document procedures, and write contact lens and eyeglass prescriptions. We evaluated its costs and ability to improve revenue in a research article published in JAMA Ophthalmology in 2015.1 No significant change was identified with total net fiscal revenue, patient volume, or the volume of diagnostics tests and procedures billed. Interestingly, the use of eye codes declined by 15.7% and use of evaluation and management codes increased by 14.7% following EMR implementation (P<.001), probably because of the ease of documenting signs and findings rather than symptoms, which would be required for an eye code visit. The analyses conducted in this study did not identify significant differences in revenue or productivity following EMR conversion in this clinical setting. The EMR incentive payments did not offset costs of implementation. This was in line with the 2015 survey by the American Academy of Ophthalmic Executives (AAOE), which showed that few respondents indicated EMR had a positive or neutral effect on net income (38%).2
One of the touted features of EMR was the ability to improve efficiency. In day-to-day practice, there were certainly anecdotal improvements. Summarized sheets of the last patient’s exams or previous injections were presented quickly, saving the time previously required to rifle through a paper chart. Charts of patients referred for surgery were available ahead of their scheduled visit, obviating the need to reorder them when patients arrived for their consultation. The ability to log in remotely enabled physicians to process missed charges or chart outside of the office. In our practice at Cleveland Clinic, we implemented a system of charge on completion which has improved our billing compliance, led to significant improved documentation of patient testing and procedures, and increased the efficiency of sending out these professional fees.
Within our system, the physician placed an order for the procedure or diagnostic test. The order then generates a form for the physician to fill out. Once complete, signing the form submits a charge with the specific procedural or diagnostic code to our billing team to review. Once reviewed electronically, the biller can submit the charge to the local carrier from processing. This has reduced our billing cycle from weeks to 2 days. It has also decreased the potential for miscoding, because it has eliminated manual entry. But balancing out those efficiency improvements has been the increased clicking and documentation required because of increased regulatory oversight and new rules.
Just as in our analysis, the AAOE survey respondents felt that EMR has a net neutral effect on improving patient volume. Only half of respondents stated that their EMR system had a positive or neutral effect on their patient volume (52%). About one-third of respondents said that their EMR system had a positive or neutral effect on efficiency (35%).
IMPROVING THE USER EXPERIENCE
Ergonomics are critical to user adoption and acceptance of any EMR system. In our practice, we incorporated the largest monitors possible to distribute a dense amount of information across a larger space. We added personal computers to the hallways to mimic the normal workflow where a physician reviews the chart before entering the room. Placing printers in the hallway minimized the distance that physicians had to travel for printed prescriptions and patient instructions. These features eased the anxiety associated with adoption of the new EMR workflow.
Drawing is a mainstay of ophthalmology practices, ours included. We first created newer pictures to represent the portions of the eye that needed documentation. We could create numerous stencils for each of the drawing photos that allowed for both the annotation of the image and insertion of text into the same exam field, eliminating duplication of work. Drawings could be placed within the chart, pulled forward to a new encounter for modification, or even added to a letter to another provider.
We improved the letter-writing and documentation capabilities of our system by implementing letter templates with drop-down menus for quick annotation. By adding an autocorrect feature to our system (converting common abbreviations such as “OD” to “right eye”) we could better communicate with other physicians who did not have ophthalmic backgrounds. We also added the capability to fax letters directly from EMR, our physicians could maintain faster contact with referring providers and their caregivers.
In a survey we conducted 3 years after EMR implementation, physicians overall felt that they spent less time talking to patients with EMR use, but they still preferred to continue using the EMR. Most physicians reported creating fewer drawings after transitioning to the EMR. Eleven physicians (44%) reported being able to complete charts consistently by the end of clinic. Six physicians (24%) reported spending less than 1 hour, while 8 (32%) reported spending more than 1 hour after clinic completing charts but none more than 2 hours.
MEANINGFUL USE, ADMINISTRATIVE, AND RESEARCH ACTIVITIES IN THE EMR
The Cleveland Clinic has supported an outcomes program within each institute since 2005. Past programs have relied on manual entry and physician reporting for the outcome results, which carry inherent reporting biases. When we developed the entry system for our EMR, a conscious effort was taken to use discrete documentation whenever possible. For example, there are few areas that have plain text boxes for entry. Rather, there are buttons and checkboxes that can be used for the documentation of imaging, procedures, and exam elements. This allows for almost completely automated outcomes collection.
By using the discrete elements within our system, we created additional data streams to determine a multitude of administrative and research functions. For example, we can monitor our usage of bevacizumab (Avastin; Genentech) in real time to determine whether our pharmacy needs to be restocked. We can evaluate the wait times by ophthalmology specialist line to allocate the proper technician-to-physician ratios. Finally, our practice has been able to monitor the frequency of use of our lasers and diagnostic modalities so we can adjust schedule templates to maximize patient flow. Research has become easier with a few clicks necessary to analyze multiple patient charts rather than the arduous process of chart retrieval and review.
Also, we have successfully submitted through the various stages of meaningful use for all physicians without significant issue, in part due to the features that the EMR provided. A cumulative amount of $983,103 from meaningful use attestation has been received by our practice for this implementation.
SUMMARY AND OUTLOOK
Has the overall implementation of EMR in retina been successful? The answer to this is highly dependent on whom you ask. It is still very clear that EMR has a fragmented group of happy and unhappy users. Many users are frustrated by the number of clicks needed to move around the medical record, especially the additional clicks necessary to satisfy requirements. The survey conducted by the AAOE elicited scores of comments from EMR users, ranging from the positive (“Could not run the practice without it”) to the frustrated (“Requires many unnecessary clicks”) and the furious (“Abysmally bad!”). Users are frustrated over their EMRs’ lack of interoperability with other EMR systems and with the myriad diagnostic instruments found in the ophthalmology office. The US Centers for Medicare and Medicaid Services hopes that its meaningful use regulations will improve usability. The recently announced rules for stage 3 of meaningful use put a greater emphasis on interoperability, and EMR vendors will need to overcome significant hurdles in intersystem communication.
For coding, compliance, and administrators, it’s been a significant improvement in capturing what is actually happening within the practice. For the super-user ophthalmologist like myself, seeing patients is faster and easier than ever, and initial concerns about spending a lot of time documenting and not talking to the patient have dissipated, replaced by the benefit of having a chart full of rich, concisely summarized information. However, like many things in life, EMR is a marathon and not a race. Consistent application of time and effort will eventually pay off. RP
- Singh RP, Bedi R, Li A, et al. The practice impact of electronic health record system implementation within a large multispecialty ophthalmic practice. JAMA Ophthalmol. 2015;133(6):668-674.
- The Academy Committee on Medical Information Technology (MIT). What do ophthalmologists think of their EHRs? American Academy of Ophthalmology. November 2015. https://www.aao.org/eyenet/article/what-do-ophthalmologists-think-of-their-ehrs