Article Date: 5/1/2006

information technology
Breaking the Paper Habit
It may be the most difficult transition your practice will make — and the most rewarding.
By ReN´┐Ż Luthe, Senior Associate Editor

For those O.D.s still on the fence when it comes to bringing your practice into the paperless mode, James K. Kirchner, O.D., of Lincoln, Neb., has some advice: "The longer you wait, the more difficult and expensive it will become. We are in an electronic world and that is not going to change."

Practitioners who have already bitten the bullet regarding replacing the written record with an electronic one say the bumpy transition was well worth it. They count increased efficiency and productivity — not to mention profitability — among the benefits. The last may come as a surprise to some, given the cost of computer hardware and software. These pioneers will help you embrace the inevitable by explaining what you should look for, as well as how much better electronic technology can make your practice.

Consider these issues

While all the optometrists who've gone paperless hoped for benefits such as improved charting and more legible doctor's notations, even the most tech-savvy had concerns about giving up their paper forms for an electronic database that would hold all a practice's most crucial information. Their concerns before transition included cost, the learning curve for the new technology and it's effect on staff, the ability to customize software templates for the practice's needs and how to handle a system crash. The documentation of exam findings also figures high on the list of concerns.

"This is the part of the system that I as the doctor mainly use," explains Sheldon H. Kreda, O.D., F.A.A.O., of Lauderhill, Fla. "Many Electronic Medical Records (EMRs) require extensive typing and data entry. This turns our focus away from the patient and onto the keyboard, which is unacceptable." Additionally, O.D.s record many findings through drawings or annotations. These kinds of documentation don't lend themselves to the typical fields found in computer databases. "I needed an EMR that would accommodate different types of office visits and permit me to enter data in a manner I've been accustomed to," Dr. Kreda says.

Get a Plan

Veterans agree that for a successful transition to paperless practice, a careful game plan is a must. This entails:
Ensuring that the computer network is functioning, including Internet access, anti-virus security, data back-up and printers
Installing the practice management software on the network and checking that it's functioning properly, with appropriate security levels assigned to employees
Making a blueprint of software implementation in stages
Scheduling follow-up training with your software vendor to address post-implementation issues

How to select a system

When it comes to buying the equipment you'll need to get started, veterans say you should select a vendor that is stable and offers resources such as significant customer support and other indicators that the vendor is in it for the long haul. The equipment should be a major line of business for the vendor. "All too many software packages have little to no support and should something happen to the developer, a serious problem would exist," warns Richard Edlow, O.D., of Baltimore.

It's also essential to think about what your practice's needs are so that you don't buy something more complicated than necessary, and to talk with colleagues who've already gone paperless. "Interview not a computer guru, but an O.D. with a very average understanding of computers," says David B. Seibel, O.D., F.A.A.O., of St. Louis. "If the system works for him, it may work for you." Veterans were unanimous in their recommendation to see a program in action in at least two other practices before buying.

Compatibility — both personal and technological — is another important consideration. Are you and the software a good match? "Look for a system that makes sense to you," advises Anthony S. Diecidue, O.D., of Stroudsburg, Pa. "Does the system work the way you do, or will you have to make sizable changes in your examination to accommodate the software?"

Then, consider whether the system is a good match for your other practice management systems. Make sure the new system will interface with your current practice management system. Dr. Edlow suggests using the same vendor for both practice management software and EMRs. And don't take a sales representative's word that their instruments and systems will synchronize with each other, warns Dr. Seibel.

Expect these benefits

For all the care required to find the optimal system, practitioners who made the change to paperless feel that the benefits make the effort more than worthwhile. According to them, the change makes nearly every aspect of optometric practice better — in terms of greater efficiency and profitability, as well as improved patient care. Here's a closer look at how the paperless practice can make your professional life easier.

►Access to patient files anytime, anywhere. Having a physical file in your hand in order to review data is no longer necessary — all you need is access to a computer. This enabled Kim Castleberry, O.D., of Plano, Texas, to conduct an exam without interrupting his vacation.

"I actually examined a patient for flashes and floaters while sitting on a balcony in Laguna Beach, Calif.," he says. "My EMR let me review the records with images, and I conversed with and managed the patient over the phone. We were both happy and I got paid while vacationing on the beach."

The implications for emergency care are obvious. Before his practice's transition to paperless, says Dr. Edlow, a typical emergency-care scenario went something like this: The patient phones the doctor on call at 6 p.m. on a Saturday night with a problem. The doctor can either guess what the patient's clinical status is or head into the office to make sure, depending on the severity of the problem. In the era of EMRs, the on-call doctor can log on to office software, look up the patient's chart and confirm allergies, current medications, etc.

A leaner, meaner staff. Dr. Castleberry needs fewer full-time employees to run his practice. He operates a $2-million practice with two full-time equivalent (FTE) O.D.s and 10 FTE staff members — a figure that he claims is about half of a "non-paperless" practice staff. Kelly Kerksick, O.D., of Columbia, Ill., says that software enabled her practice to get 1.5 times more productivity from staff.

Faster reimbursement. Another benefit to paperless practice that will make a practi- tioner's heart sing is that practices receive payments from the insurance carrier much faster. "Claims are usually at the carrier before the patient gets home [from the exam]," Dr. Castleberry says. Software programs automatically flow the billing data to insurance claim forms and submit them. Furthermore, billing can be done at any workstation, even those in the exam room. The software also eliminates the need for double entry and legibility errors.

And should an insurance company deny a claim, today's practice management software still provides an easier route for practitioners and their staff. When this happened in the old, "paper" days, Dr. Edlow explains, someone had to go to the file room to locate the file, which could be in several spots (optical, with the doctor, re-filed, etc.). "Depending on the size of the practice, this could take 20 minutes to a day or two," Dr. Edlow says. In the electronic world, the billing clerk immediately accesses the EMR chart, corrects the claim and sends it out, all within a few minutes.

Better efficiency in every department. Look for programs that automatically flow data for refractive correction to the optical and contact lens department. Again this saves staff time and eliminates the legibility issues that cost practices time and money. The right program also lets you refill prescriptions with the click of a mouse.

In the inventory, paperless systems give you accurate numbers in real-time. This enables you to make informed decisions with sales reports and lets staff know you're monitoring inventory.

Better use of space. By getting rid of filing cabinets and shelves, you can put the space you'll save to a more profitable use. One O.D. put in additional exam lanes, allowing the practice to see more patients. There's also the option of leasing a smaller office space that will cost less money.

Marketing magic. Software takes care of scheduling and recall automatically, improving patient retention. But it also allows you to perform direct, focused marketing. For example, when a new bifocal contact lens comes on the market, you can zero in on your over-40, nearsighted patients with less than a diopter of astigmatism and notify them, as the lens' target audience. "We can find almost any combination of marketing targets in minutes," says Dr. Kerksick.

What will it cost?

All Aboard!

Veterans of the paperless practice emphasized that for the transition to succeed, your staff must be behind it. It will help enormously in dealing with the later stress and extra work if they believe the change is for the better. "If staff are not involved from the first step, they may be reluctant to change and it could lead to disaster," Dr. Diecidue says.

In order for staff to buy in to the concept, however, the doctor(s) must exhibit commitment. The doctors who have successfully transitioned to paperless attribute it to their positive attitude and involvement. Dr. Diecidue recommends playing a part in every aspect from selecting the software to installing the hardware. "Do not assign these tasks to a staff person," he says. "It will appear that you do not consider them important." The result? They won't either.

The costs associated with going paperless — buying hardware, software, networking, hiring an IT consultant to address problems and help bring staff up to speed — are frequently a major deterrent for those considering taking the plunge. "Don't be afraid of costs," says Dr. Diecidue. "The hardware is cheap to buy and cheap to replace."

How cheap? According to Dr. Castleberry, a server will run about $3,000 and workstations approximately $650. You should replace these every two years. Some say you can get hardware for less. "I've gotten workstations with a flat screen monitor for as little as $299," says Dr. Kreda. For another $100, he added pen tablets to each exam-room computer. "This enables hand-writing recognition and drawing just like those expensive tablet computers," he explains.

As for software, Dr. Castleberry estimates that an initial investment of $6,000, then $600 per year for license renewal and support for practice management software. Networking fees should be about $600 for switches, routers and modems. You'll also need to replace these every two years.

Other expenses include electronic claims clearing house, voice over IP and data back-up services. Initial set-up fees are about $2,100, Dr. Castleberry says, then $450 per month. Smaller practices, he notes, can do it for much less.

And while the practice will need a computer consultant at its disposal for the inevitable problems, an in-house IT person is seldom necessary. "A system that complex is overkill for the average Joe," Dr. Kreda says. "We run nine computers with equipment designed for simple home networking, and I'm sure that's fine for the typical practice."

Just make sure your software vendor has support resources that are convenient for your practice. Despite the start-up costs for a paperless practice, it will soon save you money. "We've paid for the system already through our staff savings," says Dr. Kerksick.

How to start

If you've decided to embrace what its proponents refer to as the inevitable transition to a paperless practice, it's essential to have a plan. According to these experts, it is as crucial to success as choosing the right equipment vendor. These experts report that the planning stage required at least two months (see "Get a plan," on page 39).

During this phase, you should establish a blueprint and a timetable, says Dr. Castleberry. He advises implementing one piece at a time, as implementing the whole package at once would be overwhelming for most. He suggests starting with a practice management system. The O.D.s interviewed for this article started with tasks such as billing, recall, appointments and frame inventory. They added new functions after staff had mastered the initial ones and improved technology became available.

"Our journey to a paperless office has taken close to 20 years," says Dr. Kreda. "At first we had a single computer to maintain patient demographics and recall. The appointment book runs our practice and our electronic appointment scheduler was a big step up." Then, as third-party payers became an increasingly significant presence, Dr. Kreda implemented computerized accounting. "At this point," he says, "a single computer made as much sense as an office with one phone."

Moving to EMRs from paper charts is the next step, but one that O.D.s typically approach with more trepidation. "If you're not using an EMR now, start slowly and get your feet wet," Dr. Diecidue says. He began with simple prescription tracking before moving into full EMR.

Find a program that interfaces with your practice management software — preferably from the same vendor for optimal compatibility. Dr. Castleberry recommends purchasing a practice management package that features an EMR module.

And be aware that the transition to EMR typically takes longer than the practice management functions. Dr. Edlow says that while it took only two to three months to see all patients "electronically," it was 18 to 24 months before the practice was no longer using paper charts. Finally, Dr. Kirchner warns that with EMRs, you must have an audit trail built into the software that allows viewers to determine who created the record.

What do to with the paper files as you transition is another issue. Established patients, of course, already have paper charts. Dr. Kreda saw two alternatives for this quandary: scan patients' existing records into the database, or use their paper files alongside the EMR. "The latter was what we chose and the staff loved me for it," he says.

Finally, remember that daily back-up of data is essential to prevent loss of information in the event of a disaster.

Expect challenges

For all the benefits paperless practice can deliver, there are, inevitably, some disadvantages.

For one thing, familiarity with the new software doesn't come overnight. It's likely that office efficiency will initially decrease as doctors and staff learn the ropes. For another, even proponents acknowledge that keeping the hardware functioning optimally and maintaining the network (security, anti-virus soft- ware, back-up) requires significant attention.

Then there's the specter of the system crashing and temporarily shutting down the practice. If you live in a locale where lightning storms are common, power outages are a greater likelihood. Dr. Castleberry says his practice has had three lightening strikes on or near his building that so damaged the network hardware, they had to replace it to get back to full capacity. However, as Dr. Edlow points out, in the event of a power outage, "We'd be out of business anyway."

Data corruptions are possible as well, which means you have to revert to paper back-up while data is restored. Dr. Castleberry says that in his experience, these are rare; in 15 years, his practice has been down for more than a few hours only three times.

There are staff-related considerations as well: It's likely that not all staff will be able, or willing, to change to paperless. Some staff members may leave rather than change to a very new way of doing things. And you'll need better trained — and better paid — staff who can operate your newly computerized office.

Proponents of the paperless technology acknowledge these hurdles. The change can be stressful and requires extra work from every member of the practice, so it's essential that the doctor has a strong commitment. "I don't think some practices should go paperless due to doctor's personalities, and the desire for/ability to commit to the technology-integrated practice," Dr. Castleberry says. A positive, hands-on attitude is crucial.

For Dr. Seibel, the drawbacks to paperless technology aren't limited to learning to navigate the software. He finds that EMRs inhibit his ability to develop a rapport with his patients. With paper files, he would review the patient's personal information, nickname, refraction and chief complaint before he walked into the exam room. "Before when I went in, it was just me and the patient. We had uninterrupted eye contact," he explains. "Now it's me, the com- puter and the patient."

With EMRs, he has to first turn to the computer once he's already in the exam room to learn that information — then he can turn to the patient. As he scrolls through the electronic file, clicking on fields and entering information, he must again look away from the patient and back to the computer. "So it's back and forth between the two, instead of uninterrupted eye contact," he says. With paper files, he can write and still maintain eye contact so he uses them in conjunction with EMRs.

Technical support can also be a problem, Dr. Seibel claims, because consultants may not return calls promptly, or may be overseas or in a different time zone, which becomes an issue when changes or upgrades require you to shut the system down. Upgrades can be expensive, he adds, and when you upgrade, your customized screens from your "old" program may not necessarily appear on your new, upgraded screens — they are not automatically carried forward.

Dr. Seibel says it's "kinks" like these in paperless hard- and software systems that lead him to wonder if a practice could ever truly be 100% paperless with currently available technology.

When it's time to change

While paperless technology may still fall short of perfect, it is the future. Given the federal government's mandate for medical practices to be paperless by 2010, it's not a matter of whether you take the plunge, but when. Practices can expect a bumpy road before they reach their destination. "Going paperless was the most painful event my practice has gone through," Dr. Castleberry says. "For me, the pain was worth it."

Optometric Management, Issue: May 2006