I'm very happy to report that Electronic Medical Records (EMRs) are much easier to implement than I once feared!  We installed a new system in my practice about a year ago and I must say I'm very pleased.  There was certainly a learning curve, but once my staff and I embraced it, we found the pros far outweigh the cons.  I'll share my experience with the hope that it may assist the thousands of eye care professionals (ECPs) who have not yet made the leap but are seriously considering it – or have an EMR system but are not utilizing it.

My practice may have been one of the more challenging installations because it is very large, very busy, and office procedures are highly delegated to many staff members.  We also use scribes, so the recording of exam data is not in the hands of the doctors, but is completely done by technicians.  I'll discuss that aspect as well.

Our basic plan
Every practice is different, as is every EMR system, but I found it helpful to assimilate our EMR procedures slowly.  This approach caused very little stress on my staff and we did not have to reduce our patient schedule or our practice income.

We began with formal training on our EMR system for all staff members via live and prerecorded web-based courses and an onsite trainer.  One of our doctors was appointed to be in charge of developing the system for our practice and designing exam templates.  After the training sessions, we practiced on our system using fictitious patients during any down time in the office.  Staff members simply made up patients with the last name “Training” and often used their own first name so they could return to their practice record when they had time.  The doctor in charge of EMR worked with small groups of staff to assist them with the practice sessions and to provide fictitious but believable data.

Before actually going live with EMRs, we scheduled some of our staff members as patients into our appointment system.  This gave us time in our schedule to work with EMRs in real time in our actual exam rooms, but without real patients.  This was very helpful because the patient was a technician, plus we had a scribing technician and a doctor; all were able to learn and refine their skills.  We took some of these practice patients into the optical for an eyeglass order, fit contact lenses on some and ordered special diagnostic tests for others. 

Finally, when we truly started using EMRs for real patients, we limited ourselves to only two or three established patients per day for each doctor.  And in those cases, we still had the patient's old paper record in hand as a safety net.  This showed us areas where we needed to improve and gave us time to find answers to our questions.  We kept a spiral notebook in a central location so all staff members could write down questions and make note of quirky things we learned.  We reviewed this at our weekly staff meetings and in some cases, we had to change our office procedures to adapt to the new way of recording data and placing orders.

Shortcuts and aids
My practice is still evolving as we gain experience with EMRs.  Here are some work-arounds we came up with to make us more efficient.  It was helpful to continue with our old ways as we merged into our new ways.

• An in-office worksheet.  We use a one page exam form to collect our pretest data.  This allows the technician to breeze through pretesting very quickly and not tie up our rooms and instruments while entering data.  Ideally, we will have our pretest data flow automatically into the record, but we are not quite there yet and some tests and notes are not electronic.  The pretest worksheet also proves to be a great aid for the doctor during the exam because our scribes are using the EMR to record new data and the pretest data is not always visible on the monitor.  The worksheet is simply discarded at the end of the visit because all the data was entered.
• An available PC outside the exam rooms allows doctors or staff members to look up previous records to review key information points away from the patient.
• A paper superbill.  We still like to use our old three-part receipt forms as a multipurpose routing slip and fee worksheet.  All this information is entered into our EMR or office management system during the patient's visit, but the superbill still serves as a nice organizer and back-up copy.  We still give the patient a copy of the handwritten fee slip along with the computer generated statement because it's an impressive marketing piece for the practice (explaining all that we do).
• High speed duplex scanner.  These machines are amazing and well worth the expense over cheaper multipurpose scanners.  The staff can put in a stack of papers of various sizes and it scans both sides of every page perfectly and quickly.  We did not scan all the old paper charts but we scan the records for patients as they are scheduled for re-examination.  We also scan various documents that are produced for patients, like optical lab invoices with important lens data or incoming referral letters.
• Tablet PCs and laptops.  These computers, which connect to our network database and the internet via a wireless connection, serve a great purpose as they allow us to enter data anywhere and move with the patient.

EMRs and Scribes

• Most of our exam rooms just have one computer on the side desk.  We also use a separate PC dedicated to running visual acuity software.  You could run the acuity program off the same PC as your EMR program, but it requires two video cards and I seem to have plenty of older PCs left over from past hardware upgrades that work just fine as acuity machines.
• We have a few larger exam rooms where the scribe sits further away from the doctor so we utilize dual monitors with a SVGA splitter cable.  Both monitors display the same thing.  It would be great if the doctor and tech could each have their own monitor and each could access any part of the record they needed, but there are some technical challenges with having two people access and update the same patient record at the same time.  It really isn't a problem in our practice to have the doctor and tech seeing the same thing.  If the doctor needs to look up a finding from the past, she typically just tells the tech to retrieve it.
• The scribe (technician) generally has control of the computer, but the doctor can take it at anytime.  We find wireless keyboards and mice to be a big help in the sharing process.  We also use LCD monitors with felt pads on the rubber feet so they easily slide and turn on the desk.
• I care about how the exam room looks to patients.  While one monitor on the desk looks high tech, I want to avoid the silliness of having too many computers in a small room.  I hide the PC boxes (CPUs) under the desks or inside cabinets and I run all cables and power cords behind desks and inside walls.
• The scribe can do a great job of recording during the exam and the doctor does not have to worry about the EMR program, but rather pays full attention to the patient.  EMR is yet another advantage of using scribes.
• We always had a slight waste of time in our exam process when the technician finished pretesting and waited for the doctor to arrive to begin the exam.  Our doctors are very responsive to their pages, but there is usually a three to six minute wait as they finish other tasks.  We now use this time to allow the technician to enter pretest data and perform other administrative tasks in the record.  This is done in the same exam room with the patient; they now wait together.

The good far outweighs the bad
I think most ECPs realize they must move forward and embrace electronic records.  While we may focus on the limitations and time-consuming aspects of EMR programs, I think we also know that paper record keeping is expensive and time-consuming in different ways.  I'm convinced that EMR systems have far more advantages than disadvantages.  I have even seen a practice building aspect to EMRs because patients are very impressed when they see us using tablet and desktop PCs to record their visit.  If you don't already have EMR, I think the time is right to shop for a system, buy one and begin using it.