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Part 1: An EHR/EMR Review from One Who Has Faced Their Triumphs and Tribulations

Posted By LeRoy Judkins, COT, OCT-C, Friday, March 30, 2012
Updated: Friday, March 30, 2012
 

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 leroyjudkins@gmail.com or comment on this post below.

 

Jud

 

 

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.

 

 

Tags:  EHR  Electronic Records  EMR  Meaningful Use 

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Permalink | Comments (12)
 

Comments on this post...

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Denice A. Barsness, CRA, COMT, ROUB, CDOS, FOPS says...
Posted Friday, March 30, 2012
LeRoy

What a thoughtful and well written post! I'm just in awe of the next generation of ophthalmic imagers and the many faceted layers someone exactly like yourself brings to the forum. What an amazingly interesting time to be involved in ophthalmic imaging- patient care ( always number one!) challenging work, and the ability to interact with so many of us simultaneously using a variety of social networks. We've come a long way from the darkroom!

Denice Barsness
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LeRoy D. Judkins says...
Posted Sunday, April 01, 2012
Given I have a bit of pride in having been asked to write a blog entry for the OPS I was inclined to share a link to this page with my kid brother. Since he is my brother, after reading this page, Sean was quick to point out potential errors in my statements. I used the word “fine” in regards to what will happen if a practice does not implement a Meaningful Use system in an allotted time frame. The word fine is a bit of a misnomer however. If a practice does not comply with Meaningful Use there will be a reduction in Medicare reimbursements. No actual fine will be assessed. Payouts from private Insurances will not be affected. Theoretically a physician could forgo an electronic system, avoid seeing any Medicare patients and not be affected by Meaningful Use. There is a hyperlink at the end of the second paragraph that takes you to the CMS website for more information about Meaningful Use if you are interested in understanding more. Thank you to all those who have taken the time to read these blog entries. Please feel free to comment or contact me if you have any questions or queries.
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LeRoy D. Judkins says...
Posted Sunday, April 01, 2012
By the way, thank you Denise. You are correct, it is an interesting time to be in our field. Technology has certainly found its way into our world.
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John C. Peterson MBA-ITM says...
Posted Monday, April 02, 2012
Our Epic/Kaleidoscope "Go Live" is next Tuesday. We had training last week, and my impression is that they have accounted for most if not all of the branches of the tree that comprises a multi-specialty eye clinic's capabilities. Ironically, what has me worried is the opinion, from management, that the EMR will also handle the patient movements within the clinic. I'm on record as stating that eliminating our little sheets and slips of paper that enable the many "hand-offs" that need to happen is a disaster waiting to happen. Over beers on Saturday, an Epic employee friend of mine chuckled as I vented my dilemma. My hope is that reason will prevail.

You're right, Jud, in stating that ophthalmology is unique in the complexity of visits and the number of tests administered in-clinic. On a busy day this place is a beehive, and we need little routing sheets to get people to where they need to be on time, and in the proper order. -John
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LeRoy D. Judkins says...
Posted Monday, April 02, 2012
John,

We use routing sheets as well. We actually use the patient's billing sheet that has their times and tests associated with that day's appointments. We found that we could not do without a physical "bookmark" as the patient moved through the clinic. Unfortunately patients would occasionally lose these billing sheets or take them home with them.

Good luck with your transition. I would be interested in hearing updates as you progress forward. I would also enjoy hearing what you think about Kaleidoscope. That was a system we looked at when it was initially released. I imagine it has changed since then for what I hope is the better. Have a great day.
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Sarah Moyer CRA, OCT-C says...
Posted Monday, April 02, 2012
Jud- Could you upload a copy of the billing sheet you use? If it doesn't work on the blog, could you do it on the Forum. I'd love to see it!

Sarah
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LeRoy D. Judkins says...
Posted Monday, April 02, 2012
Sarah,

It is just a sheet with ICD and CPT codes. There is nothing particularly special about it. It is printed from our practice management system so it includes patient information such as demographics and their scheduled appointments. It is not really designed to help with the way a patient moves through the clinic. If you still want to see it let me know and I will send you a copy.
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John C. Peterson MBA-ITM says...
Posted Thursday, April 05, 2012
Whatever gets used as the "bookmark" that guides the patient around the clinic, it should at the least contain demographic/appointment information, but be shredded at the end of the day. Our patients will never have them in their possession, our techs escort them from place to place.
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Timothy J. Bennett CRA OCT-C says...
Posted Friday, April 13, 2012
Based on suggestions in the OPS forum, we just created an interest group page for EHR/EMR. Any OPS member can navigate to the page and join to contribute to the forum/blog, etc.

http://www.opsweb.org/members/group.asp?id=99895
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Stuart B. Alfred, CRA, OCT-C says...
Posted Saturday, April 14, 2012
Many of you may find this article of interest:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC353015/
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Stuart B. Alfred, CRA, OCT-C says...
Posted Monday, June 11, 2012
John,
Could you please comment on how your Epic?Kaleidoscope GoLive has gone? My understanding is that overall Epic has the most accepted EMR platform among hospitals and ambulatory facilities. I wonder if they are headed to become the next Microsoft of the EHR/EMR software market?
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Stuart B. Alfred, CRA, OCT-C says...
Posted Thursday, September 06, 2012
John, can you comment on how well the Epic "Go Live" went?
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