Successful implementation of an EMR is challenging for academic institutions

Ophthalmology departments typically lag behind their parent institutions in implementing this technology.

Issue: October 1, 2000

ByJeffrey Wick, MD

Although the presence of information technology is becoming more pervasive, the implementation of core informational architecture in health care lags behind other areas of industry and society. The use of information technology in medicine has been primarily restricted to stand-alone software, such as billing systems and, more recently, Internet activities. The Internet, in particular, has created an additional source of knowledge for both the patient and the provider. However, the digitization of clinical information has been slower to evolve.

The purpose of this study was to assess the use of an electronic medical record (EMR) within academic ophthalmology practices and to assess the value such information systems produce for these practices.

Questionnaires were sent to 123 academic medical practices nationwide to chairpersons, program directors or other equivalent full-time faculty members. The questionnaires were anonymous, but were number matched so that multiple responses from a single institution would be averaged and treated as one entry for data analysis. The institution response rate was 80%, with 99 responding. Academic ophthalmology practices were selected because they tend to be larger, more diverse, have a research mission, usually have sufficient financial reserves for capital expenditures, need enterprise-level solutions, need to integrate with other specialties and are the teaching ground for new generations of ophthalmologists.

EMR definition

The questionnaire defined an EMR as a comprehensive software package to permanently store and archive clinical data that the providers use on a daily and routine basis. This definition explicitly excludes practice management software or stand-alone outcomes software. Although these latter types of software add value to the practice, their implementation is far less complex than an EMR. An EMR is the linchpin of a highly developed information infrastructure.

The first part of the survey was designed to determine whether academic practices were using an EMR and, if not, why. The second part of the questionnaire was for those practices that had already implemented an EMR. This second part was designed to assess the level of functionality and to determine whether or not the EMR was adding value to the practice. Most results are given as descriptive statistics, and percentages are rounded to a whole number.

Results

Approximately 85% of the respondents indicated that their academic practice did not use an EMR according to our definition. To assess why these practices had not pursued an EMR, the non-users ranked a Likert-scale from 1 (not important factor) to 5 (very important factor). The results are shown in the table. As noted by the very low score of 1.8, most non-user respondents apparently felt that an EMR would provide benefit to their practice. Unavailability of suitable products was given an average score of 3.0, and the potential cost was more of a concern at 3.5. The highest score was 3.9 and reflected a real or perceived lack of administrative and/or technical support.

Approximately 14% of the respondents indicated that their academic practice did use an EMR according to our definition. However, judging from various free-text comments on the surveys, at least nine of these practices appeared to be very early in their phase of implementation. The author advises caution in interpreting the data from this group because implementations are often prolonged events — months to even years — and many benefits have yet to be realized.

EMRs are known (or strongly believed) to contribute to high quality, efficient patient care by several mechanisms. Two obvious benefits of all EMRs are increased availability and legibility of patient information. Advanced mechanisms are noted below along with an explanation.

Quality control: Four of the respondents indicated that their EMR promotes quality control and outcomes analysis. Calculation of surgeon complication rates or surgeon surgical factors are good ophthalmology examples. While many practices in the private sector use stand-alone outcomes software, this method of tracking outcomes is a productivity drain because of double data entry, often restricted to select procedures, and may suffer from inherent bias (eg, tendency to under-record complications).
Decision support: Posting or suggesting preferred practice patterns and optimal medications are good examples of decision support. Although this function is technically difficult and may be rejected by insecure physicians, the use of decision support has been shown to promote better and more cost-efficient health care in well-designed studies. In our survey, only two practices appeared to offer decision support through their EMR.
Alert monitoring: The detection of drug-drug interaction or critical values are good examples of alert monitoring. Alert monitoring has been shown to decrease adverse drug events, which are a major source of iatrogenic injuries within our health care system. Six respondents indicated that their EMR offered this level of functionality to some extent. Alert monitoring can be very simple or complex from a technical standpoint depending upon the desired result.
Research: Six respondents said that they plan to use the EMR to promote clinical research. Data can easily be extracted from databases to support clinical studies, especially at the population-based level.
Image archiving: This function is important in ophthalmology because of the shear volume of images produced. Four practices offered this capacity through their EMR. Again, this number does not include stand-alone systems. Image archiving is not technically difficult, but requires enormous storage capacity.
Cost control: The return on investment is impossible to calculate for an EMR and, therefore, was not directly addressed in this survey. However, cost is an important consideration in choosing whether or not to implement an EMR as noted by the non-user respondents. The cost of an EMR can be staggering, and conventional wisdom says that the up front cost (eg, client licenses) represents only a small portion of the true cost of these systems. On the other hand, an EMR can have a favorable cost/benefit ratio if it produces better documentation, better coding and better inventory control. Finally, the cost of storing, archiving and retrieving paper records is not insignificant, ranging from $4 and up per chart, depending on the setting.

No institutional EMR provided all benefits listed above according to the user-respondents.

Ophthalmology department behind

Several other noteworthy observations were made. First of all, a number of respondents indicated that their parent institution used an EMR even though the ophthalmology department was still paper based. This fact is not surprising considering the uniqueness of the specialty. Secondly, there appeared to be at least two disasters: academic ophthalmology practices that installed an EMR but actually removed it and reverted back to a paper system. Our survey did not ask this particular question, but this information was gleaned from free-text comments. This failure rate may actually be underrepresented and certainly represents an enormous loss of capital, productivity and organizational effort. Although this article does not do justice to the potential benefits of these systems, these failures serve as warnings to institutions that trivialize this endeavor.

Challenging, but needed

The successful implementation of an EMR may represent one of the more challenging endeavors an academic institution will undertake. Academic practices have not uniformly created a modern informational infrastructure, and ophthalmology departments lag behind their parent institutions. The difficulty arises not from technology but from organizational, political and cultural barriers. The respondents are an elite group of ophthalmologists who, as indicated by their responses, recognize these barriers. However, a few departments appear to be trailblazing the way. Hopefully, in time, those departments will leverage their information technology at the enterprise level and gain competitive advantage in quality management, research and cost control.

For Your Information:

Jeffrey Wick, MD, can be reached at University of Utah, Department of Medical Informatics, AB 193, Salt Lake City, UT 84132; (801) 581-4080; fax: (801) 581-4297; e-mail: jeffreywick@yahoo.com.

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