Article Date: 11/1/2005

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case study

Back to the Future of Paperless Practice
A veteran discusses the pros and cons of being on the technological edge.
Plano, Texas

After 12 years of "paperless practice," I now read articles about the practice of the future and chuckle to myself. I have enjoyed the fruits and endured the labors of the paperless practice of the future for more than a decade. I did my first electronic examinations in 1993 with a DOS-based medical records system; now I use electronic health records' software (EHR) (ExamWriter by OfficeMate). There are many other options as well. I have learned that for some practices, the future is now — you don't have to wait; for others, it's in the future and they should hold off. And for a few practices like ours, the future is in the past. I've learned a few things along the way and I've been asked to look back to the future of EHR from a veteran's perspective. Here is what I know.

First the fruits

Let's start with the bonuses of practicing paperless. I run a $2-million dollar practice with two full-time employees (FTE) O.D.s and ten FTEs — that's about half of a "paper" practice's staff. Our paperless practice reduces office staff demands and increases productivity for several reasons.

> Increased receipts. Our collection rate exceeds 95%, most of which comes in 14 days or less. The electronic claims system is paperless and automated, requiring no staff intervention to submit most claims. Coding procedures and diagnosis takes place in the exam room through the EHR software.

Billing and appointment scheduling can take place in the exam room or business office, reducing demand for office staff and decreasing the check-out bottleneck. Electronic claims go out the same day, often before the patient leaves the office. The software automatically scans the claims for errors before transmission and once again at the clearinghouse to prevent errors. Soon we'll be able to post insurance payments electronically, further reducing demands on business office staff.

> Automated contact lens lab orders. The software automatically generates contact lens lab orders and prescriptions at the completion of the exam or at a later desired time. The software system I chose pre-populates, or automatically completes, these orders and prescriptions with Rx information. This makes a patient's telephone or office order a one-click process. The lab order can be printed out for submission to the manufacturer or we can use an online service (VisionWeb) to submit automatically from the exam room.

This reduces the demand for office staff to process and track orders. Fee slips are "auto-populated" with billing information from the lab order, improving billing accuracy.

> Automated spectacle lab orders. Just as with contact lens orders, spectacle lab orders and prescriptions are generated automatically at the completion of the exam or at later times. The EHR software also pre-populates them with Rx information. This information is available to the optical with one click. Patients select frames from the online data base, automating the frames completion and coding screens. Lab order information automatically populates billing screens, reducing billing and coding errors. It also significantly reduces the amount of time per transaction. The lab order can be printed and submitted to the lab or transmitted directly to the lab.

> Automated correspondence. Our EHR software prints letters with exam findings to referring doctors at the conclusion of the exam. The letters are faxed or e-mailed to the referral doctors, usually before the patient leaves the office. This eliminates dictation services, postage and handling costs.

> Easy, accurate documentation. Point and click menu options with customizable exam templates in our EHR software allow the doctor or technician to document exam findings easily in a format that is similar to paper charts. This eliminates the need for a scribe. Importantly, everyone can read the doctor's writing.

> Computerized drawings. I chose a software program that provides familiar drawing templates to document findings similar to paper forms. It uses the mouse, electronic pen or touch screen to create the drawings. This provides an excellent tool for extended ophthalmoscopy or any anterior segment or posterior segment findings. There's even an on-screen Amsler grid to document macular defects.

> Eliminates the paper chase. The EHR eliminates the paper chase. We have not searched for a chart in more than a decade. Our business office is one third the size of a traditional business office because we have eliminated storage and management of patient charts. The personnel costs of chart management are also eliminated. These costs savings are significant and often underestimated.

> Electronic appointment scheduling. The appointment scheduler eliminates the messy paper appointment book at the front desk. It also eliminates a major practice bottleneck, allowing patient scheduling at any one of 30 workstations in the office. We frequently schedule a patient's next appointment in the exam room. Patients love not having to stand in line at checkout for their next appointment. This feature not only increases practice efficiency, but also increases employee productivity by allowing everyone in the practice to schedule appointments and share practice resources.

> Automated appointment confirmation. Our software program allows us to confirm appointments and track them from any workstation. The computer can even be used to automatically confirm appointments, eliminating dependence on staff to do this important but mundane task. Electronic appointment confirmation can improve revenues by decreasing no-shows and at the same time, decreasing staff costs.

> Automated recall. Automated recall and other practice correspondence can be done through an electronic telemarketing service or through traditional mailings. We chose a system with a realistic voice ("Amy") that recalls patients.

> Automated notifications. Electronic notification of spectacle and contact lens lab orders lets patients know when their eye wear is ready. The voice-enabled appointment confirmation works via telephone and is interactive with the patient who receives the call. This prompt notification increases patient satisfaction. Again, the service decreases staff costs. The electronic voice is so realistic, some practices have patients wanting to meet "Amy."

> Patient exam reports. Our software includes a feature that communicates exam findings with a printed report given to patients at checkout. The doctor or technician performs these reports with just a few keystrokes in the exam room at the conclusion of the exam. We have been doing this for over 15 years and it improves our patients' satisfaction with their visit.

> Therapeutic Rx management. The EHR software allows us to manage medications electronically at any workstation. This eliminates the cost of pre-printed pads and reducing transcription and reading errors at the pharmacy.

> Online staff training. We now do staff training online via the internet 24/7. Our EHR vendor provides Web-based staff training, so this reduces the cost and time of personnel-based training.

> Equipment integration. We've integrated Humphrey Visual Fields, Optomap, retinal photos, scanning laser ophthalmascopy, corneal topography, automated lensometry, motorized refraction, corneal topography and Marco 3D wavefront equipment into the examination rooms. You can easily view results and demonstrate to patients on the computer monitors. This impresses to patients and saves the cost and inconvenience of printing results.

> Less paper. There really is less paper in a paperless practice. While EHR practices don't have paper charts, the paperless effect doesn't stop there. There are no forms for patients to complete at check-in. We scan insurance cards and eligibility/authorizations into the EHR. Explanation of benefits (EOBs), patient and medical correspondence are all scanned into the EHR. We also scan testing results from non-interfaced equipment into the EHR "eDocuments" folder.

> Patient response. Patients like the EHR experience and are beginning to expect it. The media frequently reports studies showing EHR practices and hospitals make fewer mistakes and provide better care. I believe this will drive patients to EHR practices in the future.

Now for the labors

Though the list of the disadvantages of EHR is short, it is significant. In fact, transitioning my practice to EHR is one of the most stressful changes that ever occurred in its 22-year history. For my practice the no pain, no gain philosophy applied.

> Employee costs. We lost several good employees in the transition from paper to EHR. Some employees simply cannot make the transition to technology. We relocated three good employees to other paper-based practices. A higher skill level is required to work in an EHR practice, one with training in computer basics. While this increases the per-employee costs, fewer employees are necessary due to increased productivity.

> Hardware costs. The cost of installing, maintaining and upgrading hardware is significant. Our practice has two servers and 28 workstations. We upgrade workstations and servers about every two to three years. I recently replaced a dozen Windows XP workstations with the latest Dell technology and 19" flat panel monitors for about $700 per workstation. We installed a state-of-the-art Dell Server running Windows 2003 with dual Xeon processors, redundant power supply and mirrored redundant hard drives six months ago for about $3,000.

> IT administration costs. It's good idea to have someone on staff who can do basic IT administration. I do most of this and have trained one of our staff doctors to do basic IT tasks as well. Additionally, I have a Microsoft-certified IT professional who comes in when I feel I'm in over my head. This approach to IT administration keeps costs down, but it does require staying current with the basics in IT administration skills.

Optionally, you can outsource all IT administration on a retainer or do it on an as-needed basis. IT retainers provide on-site routine maintenance of software and hardware on a scheduled basis. IT retainers cost around $100 per computer per month. IT professionals can be hired on an as-needed basis at a rate ranging from $30-$130 per hour.

> Software costs. EHR software should include office management, electronic medical records and patient correspondence modules. Additionally, you will need accounts payable, Microsoft Office, and antivirus software to manage the practice. The costs of initial purchase, updates and license renewals are significant and vary widely. I have found that great software is not necessarily the most expensive.

> Data loss or corruption. Data loss or corruptions from viruses, technical failures, natural causes (such as lightning) and normal everyday use are a reality. We learned the hard way to use an automated Internet-based back-up service. A few years ago our data and backup was corrupted by a virus. Our vendor recovered our data in a couple of days and had us back in business. They recommended we use an online back-up service and now every morning I get an e-mail telling me my data is safe and clean. The cost is about $50 per month for my peace of mind.

We also use Norton's AntiVirus Corporate edition software at all PCs. It's centrally administrated through one PC, updating and scanning daily for security breaches. The initial cost was about $1,500 and yearly renewals for the 30 PCs are slightly less. Good data back-up and antivirus protection is crucial. Invest in them to keep the EHR practice out of trouble.

> Hardware failures. Even with good data back-up and anti-virus protection, IT hardware failures will occur, making your data and practice inaccessible. In the 20 years my practice has been computerized I have been shut down twice due to lightning strikes. These events took out out networking hardware. Fortunately we had back-up hardware, replaced it and were back in business in a couple of hours.

We keep spare back-up computers and network switches for the occasional hardware failures. We also keep a few paper charts, with exam sheets and superbills for those rare events when we cannot access our computers — but we have needed them only twice in more than ten years.

No regrets

So what do I think about the future of EHR? I think practices that implement the technology will enjoy the fruits of the practice of the future now. Practices that do not embrace the technology will miss out on the labors (particularly the costs) of paperless practice. Today's practitioner should carefully weigh the advantages and disadvantages of each. As for me, I could never go back to a Big Chief tablet and a #2 lead pencil. OM

EHR Vendors

Company....... Web Address

CCA Medical

Chart Logic


Crowell Systems


Eye Com 2

First Insight

H Quotient

Key Medical Software


MediNotes Corporation



Prima Systems

Universal Software

Solutions, Inc.


Optometric Management, Issue: November 2005