With the advent of Meaningful Use, there has been a huge surge in the production and procurement of electronic systems for health care. Medical offices and programmers alike are scrambling to tap into the money that is out there. The promise of potential bonuses coupled with the threat of impending penalties has caused a flurry of frenzied activity in our community.
For those of you who may not be aware, there is a government incentive program encouraging health care providers to implement an electronic records system. To receive any of this money there is a set of criteria regarding what the system can do known as Meaningful Use. Some of the Meaningful Use includes criteria on how the system communicates with other systems, how patients are able to retrieve their personal information, the ability to electronically prescribe medications, and there is also a set of elements each physician is required to report on. There are different stages of reporting and the incentives are laid out over a period of years on a diminishing schedule. Eventually providers not using a Meaningful Use certified electronic records systems will receive a fine.
Pictured Above: University of North Carolina resident, Matej Polomsky, MD, reviews an OCT electronically.
Photo Credit: Sarah Moyer, CRA, OCT-C
However, rushing forward with gum drop dreams of government reimbursements is not the wisest manner in which to proceed. There are a plethora of factors, pluses and minuses, which must be taken into consideration before a system is chosen. The impact of implementing an EMR system will be more wide reaching and more grandiose than most can hope to predict. There will be hardware and infrastructure considerations, training of not just your medical staff but all supporting staff, and virtually every aspect of your workflow will change.
There is such a multitude of things we do with a tangible chart at our respective clinics. The chart is the vehicle by which a patient or a patient issue travels throughout the clinic. From the moment triage is initiated or a patient checks in, that physical chart becomes part of how most of our processes are initiated and how they migrate to completion. It seems rather insignificant on an intellectual level but you would not believe the dizzying array of issues that come to roost by changing that tangible chart into a virtual one.
We invested in an EMR system 6 years ago and it affected virtually every aspect of how we function. Months of planning went into to this endeavor. I am fortunate enough to work with some very intelligent and very broadminded individuals who were very forward thinking and systematic in seeking a process of symbiotic synchronicity. There was a very conscientious and thoughtful approach to the implementation of our program, yet pandemonium and chaos laid waste to our practice once we went live. There was a consideration or compensation for every single one of our departments and even with extensive planning things went wildly amiss. Keep in mind this was before Meaningful Use was even a term.
At my clinic we have come to the conclusion that even though we have almost mastered it, our current system is not robust enough to compete with our growing needs and will fall short of the mark of making Meaningful Use viable for us. We could implement the Meaningful Use patches our current system has recently made available to us but the loss in productivity would not justify the bonus we would receive.
We have even committed to a rather languid resolve as we shop for that next jewel of software engineering that is intended to ease all of our logistic woes. We do this completely conscious of the fact that we may not be able to achieve the full potential bonus because we understand the dire repercussions of choosing an inadequate program. Though you may get a few thousand dollars more now if you are able to attest for Meaningful Use the long term costs of this decision could end up costing you significantly more. Prudence and patience are the ideal states of being as one embarks on any journey towards a new system.
I have seen countless demonstrations of numerous systems. With the vendors at the helm of their respective systems, virtually every one of them looks impressive and appealing. I even witnessed a recent demonstration of our current system, with which I am intimately familiar, and I was rather surprised by how wonderful it all seemed with the clicks of the mouse creating a back rhythm to the lyrics of the vendor’s pitch. Seeing these demonstrations, particularly at booth events, is like listening to the songs of a siren causing you to drift towards potentially perilous rocks. It is hard not to drool in delicious delight at the promises of increased productivity, ease of accessibility, decreased man hours, and reduced paper and storage costs; essentially making your clinic and the whole world a better place.
Pictured Above: University of North Carolina technician, Toni Griffin, COA, enters data into the electronic health record. Photo Credit: Sarah Moyer, CRA, OCT-C
Sadly this serendipitous Shangri La does not yet exist. The technology towards this effort is increasing rapidly, on an almost daily and exponential rate. I believe the technology is out there to make the ideas and the ideals of an electronic records system leap from the realm of merely plausible and stand firmly on the terra firma of actual existence. As of today however, from what I have seen, the perfect and consummate collection of binary code has not come to conception and remains as mythical and elusive as the fabled unicorn. This problem is particularly true in ophthalmology.
This predicament exists in how the systems are programmed versus how ophthalmic exams are documented. If you ponder how the exam of a general practitioner goes from inception to completion, there is generally a set of vitals done at each visit, then history, chief complaint, impression and a plan. Occasionally a prescription is given. Any additional tests are then ordered and a patient moves on. The bulk of a visit can be completed in a relatively linear fashion with a set of notations put together as a set of pick lists and drop downs.
A typical ophthalmic exam is far less orderly. Our charting is done in a much less structured manner and can rapidly permutate or digress. I have always found it to be an amazing and lovely coincidence that so much of what we do in an eye exam is expressed through visual means. So much of our charting is a visual representation of how we see the patient and how the patient sees. As pleasant as this reality is, it poses a variety of challenges in writing a program that fulfills the methods we use to annotate what is done in an exam. Whether it is to have a variety of images available to us at one time, or our tendency to dissect a screen to represent the anatomical view of the patient, we have some unique demands in how we utilize our records.
The other issue that is rather unique to ophthalmology is the variety of tests that we do during a typical patient work up. Not only is there a potentially prodigious number of tests that we perform during an exam, the particular tests we do and the decision tree that leads us to this plethora of tests varies greatly from one patient to another. This is particularly true if you work in a multi-specialty practice such as my own. It would take an actuary and an abacus with scientific notation to truly contemplate all the various paths an exam can take.
If you couple the already equivocal and enigmatic nature of an ophthalmic exam with the particular preferences and idiosyncrasies of a practitioner you can imagine what a monumental task designing an appropriate program can be. If you further consider how different it is to go through the steps of a glaucoma exam as opposed to a pediatric exam the process becomes even more motley and confounding. This of course has not stopped a cornucopia of companies from trying.
Although it is a deliriously daunting and monumental undertaking, all hope is not yet lost. Though none of the systems I have seen are superbly sublime, there are still many advantages to an electronic records system. Most of us will be or are in the process of procuring a system. I will have a recommended plan of approach in the second part of this post. If you have any questions or comments or if I can help in any way, please feel free to contact me at firstname.lastname@example.org or comment on this post below.
About the Author: LeRoy Judkins is a Retinal Angiographer, EMR Administrator and Lead Medical Technician at Eye Associates Northwest, PC, in Seattle WA. He was originally trained in the United States Air Force where he worked in an eye clinic and was also a certified EMT.