Article Date: 10/1/2011

EHR Considerations for Today's O.D.
electronic health records

EHR Considerations for Today's O.D.

Evaluate your existing practice management software before moving forward with electronic records

Scott Jens, O.D., F.A.A.O.

The use of software applications in optometric practice has been in a constant state of evolution since the 1970s. Starting first as tools to track optical frame inventory, then adding the functionality of optical ordering, computerized appointment scheduling and electronic claims, the software evolved into functional practice management systems (PMS).

By the 1990s, many software companies were creating electronic exam forms, and in taking a page from the medical community, electronic medical records (EMR) were taking shape. Today, the more global phrase electronic health records (EHR) has come to encompass the fully functional software solutions that provide the platform for all of the functionality that is needed for an ambulatory healthcare facility, a primary care clinic or even a hospital.

Industry estimates for primary healthcare facilities and optometry alike show that only 20% of providers in the United States are using EHR systems.1-4 With EHR adoption being positively influenced by the federal government's HITECH Act, that number will grow quickly in 2011 and 2012. (For more information, see “The HITECH Act” below.)

Unfortunately, results of a survey done in late 2010 by the Medical Management Group Association show that doctors continue to be concerned about losing the familiar workflow conducted with paper records, while many who have purchased EHR systems feel they still face very significant barriers to getting completely settled with EHR use.

THE HITECH ACT
The February 2009 American Recovery and Reinvestment Act (ARRA) established the Health Information Technology for Economic and Clinical Health (HITECH) Act which aims to deliver $30 billion to U.S. healthcare providers and hospitals as they adopt certified EHR technology and use that technology in a manner that results in a pattern of patient care that improves the health of the American public. The process of using the EHR technology in such a manner is referred to as “meaningful use” of EHR technology. When a doctor can demonstrate to the Centers for Medicare and Medicaid Services (CMS) that meaningful use has occurred for a preponderance of all patients seen, the provider will receive an incentive payment from CMS that is a “bonus” payment beyond their Medicare patient-care receipts. This is a “positive influence” effort to move providers toward use of EHR technology.

Today's optometrist has many variables to consider in EHR adoption, including:

► Satisfaction with historical PMS functionality and concern about moving data from existing systems to new systems
► Advice delivered by speakers at national and state educational forums, EHR software vendors and colleagues who have words of encouragement or disappointment depending on their experiences
► Level of interest in the CMS EHR Incentive Program that has grown out of the HITECH Act, including assessment of the potential dollars available relative to the historical volume of Medicare or Medicaid patients in the practice
► Perception of how EHR technology may influence practice workflow, patient care delivery and practice management.

Considering this review of software in optometry stretching from decades ago to today, significant need exists for a concise overview of the key decision points that should be evaluated by optometrists as they foray into the world of EHR technology.

Taking inventory

Before even contemplating the choices for EHR technology, spend some time dealing with these four items that will help provide initial self-guidance and may reduce the time it takes to analyze options and make a purchasing decision.

1. Are you happy with your current PMS software?

If YES – Many optometry PMS software applications have been in use by doctors and their staffs for years. The familiarity with those systems breeds a strong degree of allegiance to the vendor. Since virtually all PMS software vendors have developed EHR modules that directly relate to the PMS, there should be a careful consideration of the EHR from that vendor. If that EHR system meets the expectations of the optometrist, implementing it will cause the least risk of disruption. Make sure to review your options, though, since every EHR system is unique and provides certain values.

If NO – The state of satisfaction with PMS functionality is not commonly described as “unhappy” but staff may have found ways to work around the flaws of an old PMS. Yet, they may be ready for a new solution. Speak to your business staff, reception personnel and opticians to learn about their likes and dislikes. If it's clear that the PMS software is average or worse in the eyes of the staff, check out other options. Be sure to have staff sit in during demonstrations (at trade shows, or by vendor reps online or live). While the doctor cares about EHR, the staff cares about the core PMS activities.

2. Are you a technology expert or do you have one at the ready?

If YES – Historically, software solutions have been loaded onto a powerful central computer in the practice, called a server, and then accessed by the other workstations in the practice. This network of interconnected computers doesn't just happen to work. It requires the expertise of an individual who understands information technology (IT). Some optometrists are very capable in this area and have actually been their own IT specialists for years. But IT specialists are expensive, and they're often necessary to make sure each computer on the network works properly. IT personnel are particularly necessary when software updates or hardware additions are made or when technical glitches arise. Other issues including data backup are critical for an EHR system. If you like technology and working with a network, and you prefer to have your data on discs or tapes that are always in your hands, look at EHR systems that are local server systems.

If NO – Many software solutions, including those offered by Google, Apple, and now even Microsoft, are moving “to the cloud.” The cloud terminology refers to software that isn't actually sitting on your computer, but is accessed over the Internet and whose data is stored on servers that are housed at highly secure server facilities called data centers. Software that is delivered to the customer through a subscription model and is accessed over the Internet is called “Webbased.” Doctors who prefer to avoid dealing with a clinic's computer network, server set-up, maintenance and IT specialists should consider Web-based EHR systems. While computers in the practice are still connected to a central hub for Internet access, their interconnection isn't necessary and system backup isn't done at the clinic, but managed by the software vendor. Since some doctors prefer to have information stored and managed in the practice, not all will find Web-based systems desirable.

3. How many locations will you need to have on the system?

If ONE – One-location clinics are equally drawn to serverbased and Web-based EHR systems. The one location practice with 30 employees using the system simultaneously is a different animal than that with three employees. The key to understanding what you want is to think about the cost that the vendor might have for their customer engagement. It might be that a server-based system charges per workstation, which will have variable cost effects based upon the number of computers in the practice. For a Webbased system, you must consider the total operating cost by calculating the cost of ownership (multiply the subscription fee out over a 3 or 5-year period). Another consideration is whether anyone in the practice will need to access the EHR system from home. This should be factored in whether it's by remote access to a clinic-based server or a Webbased system that may allow for direct access to the cloud from any location.

If MORE THAN ONE – Multi-location clinics have similar considerations as those with one location in that they have to consider the number of accessing employees and workstations. As Web-based systems become more prominent, multi-location clinics are increasingly intrigued by the offerings that eliminate a central server because it's somewhat difficult to interconnect many locations to one server. If multilocation clinic already has a server-based PMS, then there may be equal consideration of the server-based and Web-based options in the market. Finally, the doctor should consider how administrative activities are handled. For example, think about billing and appointment scheduling, since centralization of these duties might point to the value of having a system that allows for Internet accessibility to the system.

4. Do you consider yourself a conventionalist or an innovator?

If CONVENTIONALIST - Doctors who aren't interested in change or perceived risk are more likely to stick with EHR options delivered by large software vendors with a long-standing track records. The vendors who provide the doctor with an unquestionable history are a safe bet and should be considered first. But remember to consider the viewpoints of all of the owners and doctors in the clinic, since this is where most differences tend to emerge, especially in clinics with one established senior partner and a younger junior partner or associate.

If INNOVATOR – The optometry EHR field is quite wide, and includes many vendors who would be classified as smaller businesses that are focused only on delivering a product that they feel has value to the industry. These companies have fewer employees and a smaller corporate structure, which can make some prospective customers balk. But they tend to be more likely to provide EHR technology that has been recently developed and includes features that are considered new. These companies also tend to offer more personal support and opportunities for customers to provide direct input on product development.

Choosing an EHR

Once the choice of vendors has been narrowed based upon your personal assessment of your traits as outlined above, it's time to deal with the extensive feature list that EHR systems offer. Every national eyecare education conference in 2010 and 2011 has had at least one class on EHR. Depending on the bias and background of the speaker, the attendees have a chance to hear the good and bad about the EHR industry. No matter how many of these classes you may have attended, one truth exists: there is no single EHR system that will give you one 100% satisfaction.

Choosing an EHR should be less about trying to find ways to have computerized health records reduce your workload, because they may not do that, and more about finding the sets of features you feel will enhance the care of those patients that have trusted you up to this point in your career. There's no doubt that you and your patients will be in a new place when you meet the first time after you've installed EHR technology—the computer becomes the “third person” in the exam room and there's no avoiding it. What you need is an EHR that helps you do a better job for each patient. This list of general capabilities should be at the top of your consideration list:

1. Meaningful Use Compliant Functionality. The specifications of the CMS EHR Incentive Program for EHR Meaningful Use are related to very general EHR capabilities. Examples include software features that allow for documentation of specific patient demographics including preferred language, race and ethnicity, as well as master lists of medications, medication allergies and diagnoses. Optometrists who purchase certified EHR technology will have these features since the vendors must test each of the items on the list for compliance.

2. Ease of Use. EHR software usability isn't evaluated as part of the new certifications standards, but some software certification bodies are recommending that EHR technology eventually be evaluated for usability. Features that are part of usability include font size, color coding, consistent screen designs, minimized clicking and building in forgiveness in data entry.

Today's EHR programs will all be challenged to meet the growing list of expectations, and perhaps even standards, for usability. For now, plan to demo plenty of EHR systems that are in your scope of interest and you'll probably find the one that meets your requirements and has the shortcuts you desire by simple use-and-compare analysis.

3. Optometry-specific PMS/EHR capabilities. The list of features that software systems can provide today are too numerous to list here, but examples include the ability to electronically order optical and contact lens materials, interconnectivity with electronic clearinghouses for medical and vision care plans, ability to store images from ophthalmic instruments and devices, outbound letter-writing capabilities and intuitive documentation capabilities for eye-specific conditions (e.g. refractive, ocular health, low vision, pediatrics, vision therapy.) Integrations are also considered important, including electronic prescribing, practice management outsourcing and doctor consulting services delivered directly through the PMS/EHR platform.

While the HITECH funds are a draw to most docstors, EHR adoption is going to happen eventually because of practice process enhancement, increased office staff productivity, and the future interoperability capabilities that will allow for exchange of data between your EHR system and the systems that are used by the patients' other health care providers. OM

Considering Costs and ROI
Although the questions you might have for a software vendor might seem overwhelming, the bottom-line cost of EHR systems is difficult to ascertain with traditional checklists. Like buying an automobile, every supplier has different packages and associated programs. The key areas of consideration are:
Initial acquisition of software: Get a specific quote for your practice on the cost of the software system related to your number of users, doctors, workstations and office locations. Not each of these may factor into the initial cost of the EHR system.
Data conversion: Ask if the vendor will charge for transferring data that may be obtained from your previous PMS or EHR.
Support fees: The initial training process may have variable costs. Ask about ongoing support fees.
Annual support and version update costs: Some vendors will ask customers for an annual fee to assure version updates.
Special hardware configurations. Depending on the software, your office may need to have specific hardware installed for servers, backup and networking. Be sure that you understand any vendor recommendations on wiring.
Workstation requirements for best performance: Every system has a minimum and maximum workstation requirement. Review the costs you might incur to upgrade or replace workstations for maximum performance, and plan out costs for hardware replacement every 2 to 4 years.
Ultimately, your ROI can be calculated by determining your practice's productivity growth post-implementation versus preimplementation. But so many factors can influence your practice's productivity that the delta might not reflect ROI. By eliminating the chasing for charts that is done in offices still using paper records, as well as printing costs, the cost of EHR may very well offset the personnel and materials costs that you already experience.

REFERENCES

1. Rao SR, Desroches CM, Donelan K, Campbell EG, Miralles PD, Jha AK. Electronic health records in small physician practices: availability, use, and perceived benefits. J Am Med Inform Assoc 2011;18:271-275.
2. Ackerman K. When it comes to HER adoption, practice size matters. Available at: http://www.ihealthbeat.org/features/2011/when-it-comes-to-ehr-adoption-practice-size-matters.aspx; last accessed Sept. 11, 2011.
3. Hospital and Physician Adoption of EHRs Will Accelerate Because of Federal Incentives. Available at: http://www.darkdaily.com/hospital-and-physician-adoption-of-ehrs-will-accelerate-because-of-federal-incentives-21011; last accessed Sept. 11, 2011.
4. SK&A. Physician usage of electronic health records software. Revised July 2011. Available at: http://www.skainfo.com/health_care_market_reports/EMR_Electronic_Medical_Record.pdf

Dr. Jens has practiced optometry for two decades and has volunteered for state and national optometry associations. He is the co-founder and CEO of an optometry EHR company. He can be contacted at sjens@revolutionehr.com.


Optometric Management, Issue: October 2011