Ophthalmology advocates look forward to EMR certification of the specialty

In this third installment of a series, OSN looks ahead to what ophthalmologists can expect if they choose to implement electronic medical records.

As an organization backed by the federal government sets its sights on certifying electronic medical record systems by specialty, ophthalmology groups hope to figure into this process someday soon.

The Certification Commission for Healthcare Information Technology (CCHIT), a private, nonprofit federal government initiative, is currently preparing to certify electronic medical record (EMR) systems by specialty, but ophthalmology is not currently on the list of those specialties, according to the organization.

In December, CCHIT announced plans to expand EMR certification to medical specialties, care settings and populations. An “Expansion Roadmap” extends certification to one specialty, cardiovascular medicine. Further discussion of certification in other specialties is ongoing, according to CCHIT.

According to Lloyd Hildebrand, MD, chairman of the American Academy of Ophthalmology’s Medical Information Technology Committee, certification of ophthalmology would be beneficial in that it would promote standardization.

“I think it’s a fairly good chance that [ophthalmology] will get [certification],” Dr. Hildebrand said. “Certification is very good because as you standardize, the industry sees longer term value in investment that they make because they’re building around a standard. The users, as they buy these systems, can bank on their investment holding value because of the certification process. I think there is going to be a bigger emphasis on the subspecialty certification.”

Overall, CCHIT has certified more than 57 ambulatory, or office-based, systems and is scheduled to start certifying hospital inpatient systems this year.

AAO surveys membership on EMR adoption In 2006, the AAO surveyed its members on their adoption plans for EMRs. Some of the findings are as follows: The average cost of EMR purchase and implementation was $49,712 per physician. The average monthly maintenance cost was $1,066 per physician, the data showed. The highest-rated EMR features were improved access to medical records, improved accuracy for coding evaluation and management procedures, improved claim submission processes and improved charge capture, the data showed. The lowest-rated features included increased time needed to input data, lack of ophthalmology-specific software, high add-on costs and increased documentation time. Barriers to EMR implementation included the difficulty of inputting historical medical record data, lack of capital funds to invest in EMRs, insufficient returns on EMR investments, difficulty of comparing and selecting EMRs, and concern about integrating EMRs with existing ophthalmic imaging equipment, the summary said. Source: AAO Membership Survey on Electronic Health Records

CCHIT certification criteria

CCHIT certification is based on three criteria: functionality, interoperability and security. Dr. Hildebrand pointed out that interoperability in particular will play a critical role in certification by specialty, especially ophthalmology.

“I think some of those issues are more amenable to having a generic way to address them,” he said. “For example, I think for security, it doesn’t matter if you’re in cardiology or if you’re in ophthalmology. Security issues are pretty much the same. But I think when you start to look at interoperability and you start to look at the different types of devices that we use, the imaging, and start to look at the work flow and functionality of different clinical practices, that’s where I think there’s going to be a bigger emphasis on the subspecialty certification.”

The case for ophthalmology

In CCHIT documents submitted on behalf of the AAO, Flora Lum, MD, AAO policy director of quality of care and knowledge base development, outlined the reasons supporting EMR certification for ophthalmology. Dr. Lum cited the economic burden of adult visual disorders — amounting to a $13.7 billion toll on the total federal budget and $4.5 billion in increased Medicare spending between 1996 and 2000.

Ophthalmologists’ ability to simultaneously view multiple historical data sets over time, such as cup-to-disc ratio, IOP and use of various eye medications, would enhance glaucoma patients’ quality of care, Dr. Lum pointed out in the AAO submission.

She wrote that standardizing the requirements of ophthalmic EMR systems would create the conditions for a better standard of care.

“A requirement for efficient drawing capability and the integration of images into the record would enable this type of display,” Dr. Lum wrote.

AAO initiative to promote standards for interoperability The American Academy of Ophthalmology is supporting a sweeping initiative designed to develop interopability standards for EMR systems. The initiative, called Integrating the Healthcare Enterprise (IHE), is a collaboration of medical societies, clinicians and vendors. It seeks practical solutions to complex issues surrounding clinical system integration. The IHE does not develop standards, but rather promotes existing standard sets such as DICOM, HL7 and Web technologies. IHE accelerates the adoption of EMRs, which enable hospitals, offices and clinics to share data. The dissemination and sharing of data is important in ophthalmic settings. Using the methods devised by IHE Eye Care, ophthalmologists can accurately integrate clinical information from devices and instruments into a single system, and include vital patient demographic and examination data. The AAO is sponsoring IHE Eye Care to save ophthalmologists time and resources by developing a model of interoperability. Different vendors are participating with the Academy to make their systems interoperable. — Flora Lum, MD

AAO member survey

Despite a lack of EMRs certified specifically for ophthalmology, eye care practices will adopt electronic medical record systems at an increasing rate over the next few years, according to the AAO Membership Survey on Electronic Health Records conducted in March 2006.

The survey, which drew 592 responses (18%) showed that, overall, 71% of respondents with EMR systems in place were “satisfied” or “extremely satisfied” with their system. Also, 76% would have recommended their EMRs to fellow ophthalmologists, and 79% said they would not return to paper records, the results showed.

Also, 49% of respondents had adopted or planned to adopt EMRs within 2 years. Among those with systems in place, about 41% had adopted their systems in the previous 2 years, the survey showed.

Survey results showed a higher rate of EMR adoption among larger practices, but also indicated that adoption among smaller practices is likely to grow. About 30% of the smaller groups – or those with 10 full-time equivalent employees or less – were planning to adopt EMRs within the next 12 to 24 months, the AAO summary said (see related article on page 43 for more survey results).

Dr. Hildebrand drew a connection between certification and increasing EMR adoption.

“If anything, I think there’s going to be a real inflation in the curve once we get some form of standard that is broadly adopted and certified,” Dr. Hildebrand said. “So, I think people are realizing that this certification effort is out there. They’re realizing that those standards efforts are maturing and as those two things converge, I think we’ll see an inflation in the adoption curve.”

EMR adoption experiences

Laurie Brown

Laurie Brown, COMT, COE, OCS, administrator for Cataract Surgery Section Member I. Howard Fine, MD, of Drs. Fine, Hoffman & Packer, LLC, and Jay Slagle, administrator of Midwest Eye Care, PC, echoed some of the AAO survey results, voicing overall satisfaction with their EMR systems.

Dr. Fine’s practice implemented GE Healthcare’s Centricity 6.0 EMR, a CCHIT-certified ambulatory system, earlier this year, Ms. Brown said.

“It’s going very well,” Ms. Brown told OSN in a telephone interview. “The challenges we have [encountered] are that, at first, it does take longer for people to do their patient workups if the system is new. Within a couple of weeks, we could see that the times for the patients were very close to what they used to be.”

The Centricity EMR has a “very powerful” flow-sheet function, which lets staff manipulate data with ease, Ms. Brown said.

“There’s a flow-sheet you can create for anything,” she said. “You can graph your visual field outcomes. You can, for other specialties, look at blood pressures. We can look at tonometry, cup-to-disc ratios, etc. for glaucoma patients.”

Ms. Brown described the system as a “robust tool” that facilitates the organization and utilization of information.

“For instance, if someone calls and wants their eyeglass prescription faxed somewhere, you don’t have to thumb through every visit to try and find out when their last refraction was performed. You can look at their refraction flow-sheet and look at the last date of prescription and what it was,” she said.

Office staff can pre-load patient diagnoses, past surgeries, medications and allergies to enhance efficiency and eliminate paper charts, she said.

“Just scanning in the old record doesn’t actually give you the facility of having the medication interaction work with the allergies and that kind of logic behind the system,” Ms. Brown said. “So, what we are doing is pre-loading that information and then marking the chart if that’s been done.”

Dr. Fine’s office also uses the Centricity EMR for electronic prescribing, Ms. Brown said. Centricity EMR has been approved to interface with the SureScrips Electronic Prescribing Network, a national system that facilitates communication between physicians and pharmacists.

“It’s extremely efficient,” Ms. Brown said. “There are no more unreadable prescriptions and no more standing at a fax machine or waiting on the phone to get prescriptions sent or get an authorization.”

Midwest Eye Care started using the MedInformatix EMR, which received CCHIT certification in January, in 2000, Mr. Slagle told OSN by e-mail.

“The ease of accessibility is the biggest upside,” Mr. Slagle said. “Our patient accounts department, call center, surgery center and optical departments can pull up a medical record to find pertinent data to better understand a patient’s question without having to chase down a paper chart.”

Staff physicians can access charts from any location, including their homes, he said.

Midwest Eye Care is preparing to automate outcomes analysis for cataract surgery and looking at the possibility of using the system to suggest CPT billing codes, according to Mr. Slagle.

The practice encountered a few early roadblocks. For example, it had both paper and EMR systems for a majority of its patients for the first 5 years of implementation. The growth of new paper records slowed immediately after implementation but 60% of patients still had some part of their record stored in a paper chart because staff did not have a system to scan in tests and documents, Mr. Slagle said.

“Because of that flaw, a patient might have his exams in the EMR system but he still needed a paper chart for referring doctor correspondence or a visual field test,” Mr. Slagle said.

“If you continue to maintain your paper system, you still have the costs of medical record staff, storage space and supply costs,” Mr. Slagle said. “Move away from your reliance on paper charts as quickly as possible to avoid these duplicate costs.”

Midwest Eye Care spent about $100,000 to upgrade its servers during the implementation phase, which provided for the creation of an intranet and an enhanced e-mail system, among other benefits.

Mr. Slagle said his “wish list” of EMR features includes the capacity to integrate test results into the system. Currently, he and his staff scan in visual fields, ocular coherence tomography scans and other test data.

“Some EMR vendors say that they can integrate the test equipment with their EMR system, but unless you can manipulate the results within the EMR system, it’s no better than scanning,” Mr. Slagle said.

He noted that, despite the apparent benefits, some physicians might continue to resist converting to an EMR.

“Regardless of what we do, in some physicians’ minds, EMR will never work as well for them as their paper charts did,” he said, “but the physicians’ technicians absolutely love it.”

For more information:

• Lloyd Hildebrand, MD, can be reached at 1000 Standon L. Young Blvd., Suite 390, Oklahoma City, OK 73104; 405-271-1096; fax: 405-271-1226; e-mail: lloyd-hildebrand@ouhsc.edu.
• Laurie Brown, COMT, COE, OCS, can be reached at Drs. Fine, Hoffman & Packer, LLC, 1550 Oak St., Suite 5, Eugene, OR 97401; 541-687-2110; fax: 541-484-3883; e-mail: Lkbrown@finemd.com.
• Jay Slagle can be reached at Midwest Eye Care PC, 4353 Dodge Street, Omaha, NE 68131; 402-552-2806; fax: 402-552-2367; e-mail: jslagle@midwesteyecare.com.
• Flora Lum can be reached at P.O. Box 7424, 655 Beach St., San Francisco, CA 94120-7424; 415-561-8592; e-mail: flum@aao.org.

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