Article Date: 7/1/2011

Can an EHR Integrate All of Your Devices?

Can an EHR Integrate All of Your Devices?

Ophthalmic instruments meet new standards to streamline your workflow.

By Erin Murphy, Contributing Editor

The early years of digital imaging and data collection were ruled by proprietary software. Every device manufacturer had its own program for data, images and reports. Today, practices need to pull data from diagnostic devices such as fundus cameras, OCTs and refractive instruments into a single electronic health record (EHR). This major integration has moved the industry to standardize its data formats. These changes mean it's easier for you to get an EHR that works quickly and smoothly to enhance your workflow and help you meet the requirements of healthcare reform.

Who Promotes Standards

Sponsored by the American Academy of Ophthalmology and also supported by the American Society of Cataract and Refractive Surgery, the Integrating the Healthcare Enterprise (IHE) Eye Care initiative ( is one group that works to “address the problems of connectivity and communication so that you can have all patient data in one place.” IHE tests, refines and promotes open standards to make devices and software interoperable.

Flora Lum, MD, is the Academy's Policy Director for Quality of Care and Knowledge Base Development. “The goal is to provide open standards so that interoperability is built into every new device and software system. That way, the standards aren't proprietary, which means they don't need to cost a lot and everyone can participate,” Dr. Lum explains. “As more and more companies adopt open standards, it will become easy for ophthalmologists to integrate data and images into their records. Information from all devices, vendors and image management systems will follow a single approach to exchange data so devices can communicate with each other and the EHR.”

Open standards promoted by IHE include the Digital Imaging and Communications in Medicine (DICOM) standard for images; Health Level Seven (HL7) standards for healthcare informatics; and other related informatics standards. IHE integrates these standards into a technical framework and provides the specifications to device manufacturers and software companies. That framework standardizes data for the whole clinical and administrative healthcare experience—from check in to billing.

“In testing standards for interoperability, we're trying to come up with a solution for a real-world problem. We do that by bringing together ophthalmologists and vendors in frequent meetings, and we share everything with national and international members for free,” says Dr. Lum. “Through this process, we've found ways to integrate most major imaging technologies with electronic health records and solved workflow issues. Now we're starting to address the notes and communication done during the exam, defining continuity of care records for eye care.”

To find out if a device or software package you're considering meets IHE's recommended interoperability specifications, include an IHE Integration Statement in your request for proposal. This statement will tell you what IHE specifications the vendor has implemented, as demonstrated during “Connectathon” testing with IHE.

How Do You Get Started?

Most practices are adopting EHRs as a practical step for the future, and physicians are finding they don't need to be IT whizzes and don't need to overhaul the whole practice. Vendors assess clients' computer requirements. They evaluate things like existing PCs, image and record storage, Internet bandwidth, backup and recovery and security. You will likely have to invest in some new infrastructure, but the vendor will guide you or your IT person through the process.

While diagnostic devices, image management systems and EHRs move toward open standards, software developers are also taking extra steps to integrate your nonstandardized devices. Most EHRs on the market communicate with about 100 to 200 digital devices. Generally, vendors evaluate the devices used in your practice and explain how those devices will deliver data to their EHR.

“While focused on improving workflow efficiency and increasing patient volume, ophthalmologists today also face the challenges of declining reimbursements and thus the availability of discretionary revenue to devote to new devices. Many prefer to hold onto their current ophthalmic devices that work well for them,” explains Tera Roy, Specialty Director for Ophthalmology at NextGen Healthcare, which offers NextGen Ambulatory EHR. “That said, they still can reach the desired workflow efficiency with disparate equipment by leveraging the variety of connectivity options available from an advanced EHR vendor.”

James Messier, Vice President of Sales & Marketing at Medflow, Inc., makers of Medflow EHR, explains how data from older devices transfer to an EHR system. “Device manufacturers are slowly but surely moving toward open standard compatibility, but there are tens of thousands of pieces of legacy equipment in use,” he says. “We move information from those devices to the EHR by adding networked PCs or DICOM capture stations alongside legacy equipment, so we still have the full benefit of the DICOM workflow.”

Claudia Wasch, Product Manager for Data Workflow Solutions at Heidelberg Engineering, Inc., points to the importance of backward compatibility. “The DICOM Interface for the Spectralis OCT allows for the exchange of all Spectralis images and reports, even if the data was acquired before the DICOM interface was implemented. A complete patient record doesn't begin with the day the DICOM interface is deployed, but with the day of the patient's first exam,” she explains.

Link Wilson, President and CEO of Compulink, developers of Ophthalmology Advantage, points out that although his company is a member of IHE Eye Care initiative and their EHR supports DICOM, the company provides vendor-specific interfaces to support the mix of legacy devices and the latest new technology in ophthalmic offices.

“There's always something new coming out, so we need to have close relationships with the vendors to ensure that there's no pause in integration with our EHR,” he says. “The average client has five different interfaces to incorporate into the EHR, and we make sure it runs smoothly from the start. It's technically challenging—but it's a challenge we take on so our clients don't have to.”

Christina M. Majeed, Vice President of Business Development, New Products and Technologies at NexTech, agrees that interoperability and integration of patient images is one of the keys to leveraging EMR for better patient care.

“NexTech has developed functionality within its EMR system to capture patient images from any and all types of medical devices networked to the server and automatically import them directly into the patient's encounter note,” she says.

With an EHR system in place, practices can begin to reap the benefits of improved workflow virtually immediately. “A major challenge is synchronizing patient records across the various databases in the practice. In the past, patient information was entered manually into each system. The variations in data entry and spelling have likely created a large number of mismatching patient records,” Claudia Wasch explains.

“When moving to an electronic workflow, those mismatching records often go unnoticed and can lead to the creation of duplicate records. We take this issue very seriously. The Spectralis software scans every incoming record for potential duplicates and mismatches. It alerts the user and offers options for reconciliation. The last thing you want is to have images for a single patient scattered across multiple records.”

What's Next?

An EHR is a long-term purchase. If you're thinking of getting one now, you should know what's coming next in the industry, as well as in your own EHR.

“I think perhaps we'll start to see some consolidation in the marketplace,” James Messier says. “For Medflow, interoperability is the future. EHRs will need to communicate not only with diagnostic devices, but also with other EHR software systems in a healthcare community. Hospitals will be reaching into the community-based physicians' market. Our users don't want to be dictated to by a hospital using a non-ophthalmic based system. An eyecare EHR vendor will have to communicate with other EHR systems outside of eye care. I feel this will definitely become part of certification and meaningful use at some point, so we need to make sure we're ready now.”

Christina Majeed says she and the NexTech development team constantly work to incorporate client suggestions into their EHR system. “Our clients want the best and latest technologies embedded into their workflow, especially when communicating with patients,” she says.

“NexTech doctors are texting patients to alert them about their appointments and closing the communication loop through the patient portal by allowing patients to enter history and insurance information, chat with a nurse, or make appointments directly from their computer at home, or even in the waiting room through an iPad or PC.”

As more EHR vendors support DICOM, look for the integration of ophthalmic instruments and EHR to focus on image analysis.

Image analysis isn't the only kind of breakdown you can look for in the future. “We're working on clinical decision support that will alert you to combinations of symptoms, history, and/or test results, such as refraction or OCT scans, that may point to a specific problem,” says Dr. Lane. “And we're also introducing a business intelligence module with will allow doctors to analyze, collate and display data in the system in different ways in real time. It will be easier to pull up the right information to guide business and clinical decisions.”

But as good software becomes more complex, its design should remain simple, clean and intuitive. “As the system grows, we're passionate about increasing the EHR's ease of use in every way possible,” Dr. Lane says. “In the end, it's not about moving paper to the screen. It's about being able to access and use data in a way that you never could before.”

As EHR vendors take on more of the basics of image management, they will form or grow existing partnerships with instrument companies so they can provide ophthalmologists with the ability to analyze the data in clinically relevant ways.

“Today, with our EHR, the ophthalmologist can easily view, store and manipulate images generated by any DICOM instrument,” says Link Wilson. “Instrument vendors are headed toward major software advances as well, with automated image evaluation that will flag problems before the doctor even sets eyes on the image. We're both unified in the single integration goal to simplify use, enhance accuracy and do it all at a lower cost.” OM

Optometric Management, Issue: July 2011