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
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.
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
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
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
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.
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
Optometric Management, Issue: November 2005