Ophthalmologists face specific challenges in using EMR systems

Practice size, specialty, staffing, finances, interoperability and technical support play major roles in helping to decide what is right for them.

As a growing number of electronic medical record systems are certified and introduced to the market, practices of all types and sizes face choosing systems that are right for them.

So far, more than 57 ambulatory, or office-based, electronic medical record (EMR) systems have received a nod from the Certification Commission for Healthcare Information Technology (CCHIT), a federal government contractor. Several of these are certified for ophthalmic use.

The right system for any given office depends on practice size, specialty, staffing, finances and other factors. Ophthalmology, an information-heavy specialty in which imaging plays a key role, faces particular challenges in adopting electronic systems, according to EMR software company executives interviewed by Ocular Surgery News.

In choosing EMRs, practices need to consider interoperability, or the ability of systems to work with operating systems such as Windows and various imaging and medical record software packages. They must also weigh the costs of purchasing, operating and maintaining EMRs, according to CCHIT and various EMR experts.

Standards on the exchange of clinical data are being designed to ensure interoperability and, as a result, enhance care quality, said Flora Lum, MD, the American Academy of Ophthalmology’s policy director for quality of care and knowledge base development (see sidebar).

Practices have various resources, such as the CCHIT and AAO EMR Central Web sites, designed to educate them about EMRs and help them choose products.

OSN asked one health network executive to shed light on how large and small practices are implementing EMRs. Executives of two EMR providers commented on some of the issues that ophthalmologists face when choosing EMRs and system features that may help those users.

AAO spearheads efforts to standardize digital information exchange To communicate smoothly and effectively, electronic medical record systems need to “speak the same language.” The American Academy of Ophthalmology is spearheading efforts to develop standards for the seamless exchange of clinical data between EMR systems and also with other systems or devices such as imaging systems, billing systems and medical devices. The AAO and other medical groups, such as the American College of Cardiology, the Radiological Society of North America and Healthcare Information and Management Systems Society, are sponsoring an initiative called Integrating the Healthcare Enterprise (IHE), designed to streamline workflow and promote a standards-based exchange of clinical information The vision of IHE is to have vital information passed seamlessly from system to system within and across departments and made readily available at the point of care. Three benchmarks The IHE Eye Care has defined three benchmarks of functionality: workflow, charge processsing and evidence creation. Workflow involves the integration of information management systems with clinical data acquisition devices. Charge processing entails generating billing transactions from procedures performed with instruments. Evidence creation concerns the ability to create another document with detailed measurements and analyses and keep it with the image and patient record. IHE Eye Care aims to provide the ability to access all images anywhere and any time, display images and patient records together, and assure billing accuracy, the document said. Shared nomenclature The AAO’s Working Group on Digital Imaging and Communications in Medicine comprises physicians, vendors and user groups developing and implementing standards for the exchange of digital information in eye care, according to the AAO. An initiative known as Systemized Nomenclature of Medicine Clinical Terms (SNOMED) seeks to address the standardization of clinical terminology, a key requirement for smooth EMR function. SNOMED has gained acceptance and is rapidly becoming the international standard for clinical terminology, according to Lloyd Hildebrand, MD, the AAO’s chairman of the medical information technology committee, and Flora Lum, MD, the AAO’s policy director for quality of care and knowledge base development. The ophthalmology SNOMED subset currently includes 14,734 terms, of which 9,511 are unique to the specialty and 5,223 are similar, Dr. Lum said. “We are using the SNOMED terminology to identify online educational content so that it can be readily researched and categorized,” Dr. Hildebrand said. “We are also using SNOMED terminology to use in protocols for interoperability.” In a 2005 article in Ophthalmology, Drs. Hildebrand and Lum contended that coded terminology would make it easy for computers to search, retrieve and compare clinical data. They also pointed out the importance of clinical terminology accompanying images to provide accurate clinical review. For more information: Flora Lum, MD, can be reached at the American Academy of Ophthalmology, 655 Beach St., San Francisco, CA 94109-1336; 415-561-8592; fax: 415-561-8557; e-mail: flum@aao.org. References: Lum F, Hildebrand L. Why is a terminology important? Ophthalmology. 2005;112:173-174. SNOMED standards and updates can be found at www.snomed.org.

A critical mass of data

Large physician groups are building the infrastructure for EMR networks and “lowering the bar” for smaller groups, said Tom Williams, executive director of the Integrated Healthcare Association, a health care advocacy network based in California.

“One of the good things about having large groups at the front of the adoption curve is that it’ll get a critical mass in place of EMRs,” Mr. Williams told OSN in a telephone interview. “That, in turn, will foster a critical mass of data for data exchange and interoperability. That, in turn, will lower the bar for entry for smaller groups and so on.”

Currently, with EMRs in their infancy, it may be too early for many small practices to adopt EMRs, for economic and logistical reasons, he said. He envisioned the development of a national EMR network taking as long as 10 or 15 years.

“It’s going to be an exponential curve where it will be slow, and then we’ll see the various data exchanges put into play once they get through the standards and all the criteria on interoperability, and then it’s sort of like the Internet,” he said.

Interoperability will likely snowball as more groups adopt EMRs and networks take shape, Mr. Williams said.

“There are ongoing challenges that will be solved incrementally, at least in terms of interoperability,” he said. “It’s a chicken-and-egg situation, where an EMR makes more sense when you have access to data outside your organization and you’re able to receive it. As groups build EMR capacity, they’re in a better situation to exchange information the other way.”

Image: Medinotes

Visual medical record

Ophthalmologists need to “connect the dots” between scheduling and billing, according to Doug Mastel, chief executive officer of Mastel Precision, a company that markets ASSORT, an outcomes analysis and surgical planning software package for ophthalmologists.

Australian corneal specialist Noel A. Alpins, MD, developed the ASSORT program. Mastel Precision is the exclusive North American distributor of ASSORT.

Connecting various aspects of practice management requires an “enterprise management solution” to handle data flow from “front to back,” Mr. Mastel said.

“The conundrum for ophthalmologists is that they have the most information-intensive medical practices of any medical discipline,” Mr. Mastel said. “So, we’re focusing on the management of the quality of vision and the surgical complications. I call it a VMR or visual medical record. It’s specifically the medical record side of things with what they did in surgery, what their results are, what their visions are at most parameters, with a specific focus on astigmatism management with vector analysis.”

Seemingly small details go a long way in making EMRs more useful, Mr. Mastel said.

“The right program has to be designed and developed in conjunction with ophthalmologists. It can’t be brought from other disciplines. It has to have input and work,” he said.

Yet, Mr. Mastel was unable to name any EMRs that stand out for ophthalmologists.

“I haven’t seen, personally, an EMR that was to die for,” he said.

Technical service and support

Don Schoen, chief executive officer of MediNotes Corp., maker of the MediNotes e 5.0 EMR, voiced some optimism about EMR adoption eventually increasing among various specialties, including ophthalmology.

The federal government and CCHIT aim to motivate physicians to adopt EMRs by offering assurances of functionality and interoperability, Mr. Schoen said.

“With that said, I think some of the functionality that was developed was more for primary care and general medicine,” he said. “Some of the functionality found in certified products may not be as relevant to the specialty areas due to the initial focus of CCHIT.”

However, CCHIT may move toward certifying EMRs according to specialty, Mr. Schoen said.

One crucial element for small practices is technical service and support. Small practices are sometimes wary of adopting new technology because of staffing shortages, Mr. Schoen said.

“Doctors’ time is valuable, especially when they’re the only ones in the office,” he said. “You’ve got to be able to answer those types of issues for the small office.”

Still, physicians in small practices tend to be “entrepreneurial” and more likely to take a hands-on approach in installing and testing EMR systems, Mr. Schoen said.

Besides MediNotes e 5.0, other CCHIT certified EMRs designed for ophthalmic use include the PowerChart 2005.02 (Cerner Corp.), NextGen EMR 5.3 (NextGen Healthcare Information Systems) and VersaSuite 7.5 (Universal Software Solutions). The American Academy of Ophthalmic Executives Web site provides a list of EMR providers. Not all providers on the AAO list are known to have CCHIT certification.

For more information:

• Doug Mastel of Mastel Precision can be reached at Mastel Precision, 2843 Samco Road, Suite A, Rapid City, SD 57702; 800-657-8057; e-mail: doug@mastel.com.
• Don Schoen, CEO of MediNotes Corp., can be reached at 1025 Ashworth Road, Suite 222, West Des Moines, IA 50265; 515-327-8850; fax: 515-327-8856; e-mail: dschoen@medinotes.com.
• Tom Williams, executive director of the Integrated Healthcare Association, can be reached at the IHA, 334 Thomas L. Berkley Way, Suite 350, Oakland, CA 94612; 510-208-1740; fax: 510-444-5842; e-mail: twilliams@iha.org.

References:

• American Academy of Ophthalmology. EMR Central. Available at www.aao.org/aaoesite/promo/business/EMR1.cfm.
• CCHIT Certified Product List, testing instructions and other documents available at www.cchit.org.

• Matt Hasson is an OSN Staff Writer who covers all aspects of ophthalmology. He focuses on regulatory, legislative and practice management topics.