Viability of ophthalmic electronic medical records hinges on interoperability

Advocates hope that electronic medical records become synonymous with health care efficiency, safety, improved patient care and reduced costs. However, questions remain regarding issues such as universal standards, security and systems that are specifically geared toward ophthalmology practices.

In 2004, President George W. Bush called for all Americans to have electronic medical records (EMRs) by 2014, and EMRs are a key component of President Barack Obama’s health care reform strategy. Incentives for EMR adoption are also a key feature of the economic stimulus bill President Obama signed soon after taking office.

Electronic medical records, also known as electronic health records (EHRs), are dedicated or Web-based computer platforms or software packages designed to partially or completely eliminate paper records. EMRs perform practice management functions, such as billing and scheduling, and clinical functions, such as storage and retrieval of patient charts and images. Some systems perform both functions.

Some EMRs also handle electronic prescribing, in which patient and prescription information is transmitted from the physician’s office to the pharmacy.

Kerry D. Solomon, MD, uses two different EMR systems: one for image management and clinical charting, and another for practice management. Image: Cook D

The Certification Commission for Healthcare Information Technology (CCHIT), a nonprofit federal government contractor, certifies EMR systems. The CCHIT certifies ambulatory, or office-based, EMRs and hospital-based EMRs; certification is based on functionality, security and interoperability, or the capacity for systems to communicate with one another and integrate clinical images with patient data.

Interoperability is particularly critical to the efficacy of eye care EMRs, experts say.

Currently, there are no EMRs certified specifically for eye care, but there are systems certified for ambulatory care being used in eye care practices. In ophthalmology, committees comprising clinicians, researchers and manufacturers are devising interoperability standards, and CCHIT certification criteria for eye care EMRs are expected to be completed in 2011.

“We are trying to work toward [certification.] We want to get it,” Flora Lum, MD, American Academy of Ophthalmology policy director of quality of care and knowledge base development, said. “We applied 2 years ago, and we applied last year. We did get accepted, but we’re not starting until 2010. We anticipate having criteria in place around mid-2011.”

Ophthalmology and other specialties face a serious dilemma with EMRs. The American Recovery and Reinvestment Act of 2009, the federal economic stimulus bill, called for substantial financial incentives for physicians who adopt EMRs starting in 2011, before CCHIT-certified eye care EMRs enter the market, William L. Rich III, MD, FACS, the American Academy of Ophthalmology’s Medical Director for Health Policy, said.

William L. Rich

The AAO is urging the Senate Finance Committee to delay the incentives until CCHIT-certified eye care EMRs become available, Dr. Rich said.

“The Academy feels that the timeline for the bonuses and penalties has to be pushed back,” he said. “We’re not going to be up and running with CCHIT-certified EMRs by 2012. It’s just not going to happen. They’re talking about developing the criteria in 2011. We feel very strongly that as it’s structured now, ophthalmologists are not going to be able to participate.”

Dr. Rich strongly advises ophthalmologists to delay EMR purchases until eye care systems are certified. Those who choose to adopt EMRs sooner should do so to improve efficiencies but disregard the incentives, he said.

“My strong message to practicing ophthalmologists is that unless you’re in an integrated system like a university, do not buy an EMR because you don’t know what you’re getting,” Dr. Rich said. “If you can buy an EMR or some sort of document management system, you should base that decision on what it can do to change your efficiency at this point and totally disregard the whole issue of the bonus because I just don’t think it’s feasible.”

Incentives are up to $44,000 over 5 years for physicians who adopt EMRs in 2011 or 2012, up to $39,000 over 5 years for those who adopt in 2013 and up to $35,000 over 5 years for those who adopt in 2014. Physicians who adopt EMRs in 2015 or later face a 1% to 5% decrease in Medicare reimbursement.

Imaging and security standards

The AAO sponsors the Eye Care Working Group, which is designing Digital Imaging and Communications in Medicine (DICOM) standards for eye care, a key component of interoperability. The group comprises clinicians, users, vendors, researchers and other experts.

“We’ve been encouraging a lot of the EHR vendors to come with us,” Dr. Lum said. “We have several now, and we’re getting more.”

Work on DICOM standards is progressing slowly but starting to produce results, Dr. Lum said.

“We’re working on a visual field standard, so that’s kind of exciting,” she said. “So finally, instead of having a paper or a PDF of the visual field report, there will be actual data that you can transfer between the visual field machine and the EHR system. There’s also a macular thickness report, and that’s almost finalized. That will be ready this year, and we’re hoping manufacturers will be able to implement it by the end of this year.”

The visual field and macular thickness standards will enhance interoperability between imaging devices and EMRs, and provide a standardized format for transmitting and displaying images, Dr. Lum said.

“You can compare better when you get reports from different equipment because it’s in a more standardized format, more standardized display, and it’s easier to compare the information,” she said.

EMRs must be able to interface seamlessly with devices, especially in a specialty such as ophthalmology that relies so heavily on imaging, Dr. Lum said.

Currently, the U.S. Department of Veterans Affairs and other federal agencies require new government-purchased imaging equipment to meet existing DICOM standards, Dr. Lum said.

“We don’t have DICOM standards for everything yet,” she said. “We have fundus cameras and ophthalmic tomography, which covers [optical coherence tomography] already. Ultrasound is already covered. Refractive instruments are covered. We don’t have everything yet, but we’re getting closer.”

Another AAO group is working on Systematized Nomenclature of Medicine (SNOMED) standards for eye care, Dr. Lum said. SNOMED is a suite of standards specified for EMR certification.

“We could have interoperable health records that exchange information, but if you don’t know what someone meant by this term and someone else used another term, do they mean the same thing or are they different?” she said. “It’s not a complete semantic interoperability. … That’s what we’re aiming for.”

The AAO fully supports the efforts to develop DICOM and SNOMED standards, Dr. Lum said.

“The Academy is trying to help with these standards,” she said. “ At one display, one work station, you have everything there related to the patient; that’s what we’re trying to get.”

Laurie K. Brown, COMT, COE, OCS, administrator for OSN Cataract Surgery Board Member I. Howard Fine, MD, of Drs. Fine, Hoffman & Packer, LLC, approves of the efforts to devise DICOM standards.

Laurie K. Brown

“It’s very encouraging. It can only help,” she said. “I think it will get more vendors to adopt a specific platform so that more equipment can talk to more EMRs. You need a big voice speaking for you to help get all these ophthalmic EMR companies to work on becoming interoperable with equipment that we’re using.”

Robert J. Noecker, MD, MBA, pointed to a lag on the part of manufacturers in designing systems with DICOM standards, especially those governing the integration of patient information and clinical images.

“The idea is to keep the patient identification information right with the image so there’s never confusion or misfiling or anything like that, especially when you get into big [patient] volumes,” Dr. Noecker said. “That’s our gripe with certain vendors, that they haven’t made this information readily portable so that we can use it however we want to use it for patient care.”

After radiology, ophthalmology is the second most imaging-dependent specialty in medicine, Dr. Noecker said.

“The pushback on the ophthalmology side is always the worry about the integration of our imaging, our photographs and visual fields, and now the digital imaging technologies like [Heidelberg Retinal Tomograph] and OCT,” he said.

The security of patient EMR information is of key concern to vendors and adopters. In 2003, in compliance with the Health Insurance Portability and Accountability Act of 1996, the U.S. Department of Health and Human Services issued a rule pertaining to procedures designed to ensure the confidentiality of protected electronic health information.

“I have a lot of concerns about security,” Dr. Rich said. “How open are my records to others? Will EMR raise the risk of audits? Patient advocates will carry the ball on this issue, and their concerns have to be addressed, and the profession has to recognize them. How secure are my patients’ records?”

Thoroughly research EMRs

Prospective EMR adopters need to search thoroughly for systems that meet their needs, OSN Refractive Surgery Board Member Kerry D. Solomon, MD, said.

“First, they need to do their homework,” Dr. Solomon said. “It’s important that people look at all the different systems out there.”

In searching for an appropriate, reliable and affordable EMR system, a practitioner or administrator must scrutinize manufacturers’ financial health and range of product offerings, Dr. Solomon said.

“Due diligence is a must,” he said. “As part of due diligence, people need to look at the company’s overall health, the company’s track record, and make sure that it’s a company that will be around for 5, 7 or 10 years. You certainly don’t want to get yourself vested with a company or product that may not be in business in a few years.”

Practices considering EMR adoption also need to assess systems’ capacity to handle ophthalmic functions.

“You want to know what their experience with ophthalmology is,” Dr. Solomon said. “There are a lot of products out there that have been very well-accepted in general medicine but really don’t have a product offering for ophthalmology, or the product offering for ophthalmology is fairly limited.”

When approached by a representative of a company that aims to demonstrate an EMR system, a practice should demand a demonstration using in-house charts, not generic pre-prepared charts, Dr. Solomon said.

“Give them a couple of your own charts and say, ‘Show me how this is worked up, show me how you enter this data, show me how you enter this image. How do you manage this? Show me how I would schedule surgery,’” he said. “A lot of times they come in with pre-printed information. It’s a very slick presentation, but it’s very hard to determine exactly how the system works.”

Prospective adopters should also visit other practices to observe EMRs in action and get insight into regular EMR use.

“Physicians are under the impression that EMR is cool, slick and easy to transition to, and I would say that’s absolutely not the case,” Dr. Solomon said. “Everybody needs to be trained, from the very first staff member to the physician.”

The transition to EMRs is easier for large practices with strong information technology support, Dr. Noecker said. The cost of full EMR adoption can be about $50,000, according to some experts.

“But that said, the writing’s on the wall that by 2012 the major payer, ie, the government, is going to pretty much require that people are up electronically in some form,” he said.

Experiences of EMR adopters

According to an AAO member survey conducted in 2006, 12% of reporting practices had adopted EMRs, 7% were in the process of adopting and 10% planned to adopt within 12 months.

The survey showed that 69% of early EMR adopters were satisfied or extremely satisfied with their EMR systems, 51% reported decreased or stable costs, and 76% said they would recommend an EMR to a fellow ophthalmologist.

A total of 3,796 AAO members were randomly selected to participate in the survey; 592 members (15.6%) responded to the survey.

The median per-physician cost of EMR implementation was $30,000, and the median monthly per-physician EMR maintenance cost was $500, the survey showed.

In his practice at the Storm Eye Institute, Dr. Solomon and his staff use the IDX EMR (IDX Systems) for practice management functions and the Medflow EMR (Medflow) for clinical charting and image management. The Medflow system is designed for ophthalmology.They have received an approvable letter for CCHIT certification.

“Medflow handles all of our imaging, so that every test we do — visual fields, OCTs, IOL calculations, etc. — all get put into the EMR. We interpret them, and they stay part of the patient’s record. Interfaces are then developed to integrate with practice management systems, in our case, IDX,” Dr. Solomon said. Medflow has also formed an informal alliance with Allscripts, another practice management system.

Some vendors integrate their EMR systems with practice management and billing systems. An example of this is Nextgen, which is already CCHIT certified. Image management is then handled by another vendor such as EyeRoute (Topcon Medical Systems) or Chase, both of which have close and long-standing working relationships with Nextgen. An advantage of having the EMR and EHR (practice management) integrated is seamless data transfer, easier product updates, and one base operating system, Dr. Solomon said.

E-prescribing and automatic e-mails and faxes to patients and referring physicians can readily be done with both of these systems, Dr. Solomon said.

While helpful for a single office, an EMR system is invaluable for multiple locations, he said.

“We have been fully electronic for several years. Many of our residents who have been paperless for their training are getting set up in private practice to be paperless from the beginning.

“My recommendation for physicians looking to go paperless: do your homework, decide what your office needs are and what system best fits your needs and your budget. In addition to my practice, many of my colleagues are glad they made the transition,” Dr. Solomon said.

Dr. Noecker and colleagues at the University of Pittsburgh Medical Center have used EMRs for about 10 years. Currently, they use the EpicCare Ambulatory EMR (Epic Systems), which received CCHIT certification in 2008, for outpatient records and Stentor (Philips), a radiology system, to manage clinical images.

Robert J. Noecker

“We do all of our operative reports electronically a few minutes after we do the surgery,” Dr. Noecker said. “We have e-prescribing now. Everything we do now is electronic.”

In his practice, full EMR adoption took about 6 months, Dr. Noecker said.

“That’s kind of the crucial time because that’s when patients are starting to return for the second visit,” he said. “Certainly with any change in documentation, the hardest time is the first time a patient comes in. What we did initially was we kept their paper chart, but all documentation going forward was done electronically.”

The integration of clinical images has allowed his practice to rely less on drawings.

“Ophthalmology, traditionally, has been largely dependent on drawings,” he said. “What we found was that since we had a picture right there in our note, it made it easier to give up the drawings. The picture is pretty good. It’s usually better than our drawings.”

Having integrated medical records enhances patient education, Dr. Noecker said.

“Being able to pop up a patient’s optic nerve photograph or [Heidelberg Retinal Tomograph] on the screen and show that to them has really enhanced our patient education about glaucoma or whatever their disease is,” he said.

Integrated EMRs also help clinicians assess the efficacy of various treatments.

“The digital imaging systems generate pictures, but they also generate a tremendous amount of numerical data that we can’t tap into right now,” Dr. Noecker said. “[Integration] will make it a lot easier when they can just shoot us the numbers, and we can graph that and find trends over time, see if our interventions are working.”

E-prescribing

In 2007, CCHIT added e-prescribing capability as a requirement for ambulatory EMR certification.

GE Healthcare’s Centricity 6.0 EMR, a certified ambulatory EMR, has an e-prescribing function, Ms. Brown said.

“It’s going very well,” she said. “It’s a very easy thing to move to. Basically, in our system, when a patient tells you what pharmacy they want to use, instead of just defaulting to a fax, if that pharmacy has electronic availability — and we have notified all of our pharmacies that we do — it will pop up as electronic, so there isn’t any real big step that you have to take as a prescriber.”

The transition to e-prescribing is seamless for practices with EMRs equipped with that function, Ms. Brown said.

“If you have an EMR, the vendors are set up — most of them — to do e-prescribing, so it’s within your system and it’s just another thing that you turn on in your system,” she said. “For instance, we were electronically faxing prescriptions through our EMR, and electronic prescribing is very similar. It doesn’t look any different from the doctor using the EMR. … It’s basically the same functionality on our end. So it’s not a big deal clinically if you’re already using an electronic process.”

The transition to e-prescribing is more involved for practices with paper charts.

“It’s an added workflow for them because they will likely need to gather up all the charts and have someone sitting at the end of the day entering them into a program,” Ms. Brown said. “It’s a new assignment for someone to take the paper chart information and get it into a computer system to do e-prescribing.”

CCHIT chose Surescripts and other e-prescribing networks to certify e-prescribing functions for ambulatory EMRs. Surescripts was also among five test sites included in an e-prescribing pilot program conducted by the Centers for Medicare and Medicaid Services and Agency for Healthcare Research and Quality. – by Matt Hasson

Do EMRs improve patient care and reduce costs for all medical specialties?

References:

• Certification Commission for Healthcare Information Technology. www.cchit.org. Accessed June 24, 2009.
• Chiang MF, Boland MV, Margolis JW, Lum F, Abramoff MD, Hildebrand PL; American Academy of Ophthalmology Medical Information Technology Committee. Adoption and perceptions of electronic health record systems by ophthalmologists: an American Academy of Ophthalmology survey. Ophthalmology. 2008;115(9):1591-1597.

• Laurie K. 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.
• Flora Lum, MD, can be reached at American Academy of Ophthalmology, P.O. Box 7424, 655 Beach St., San Francisco, CA 94120; 415-561-8592; e-mail: flum@aao.org.
• Robert J. Noecker, MD, MBA, can be reached at the University of Pittsburgh Medical Center, Eye and Ear Institute, 203 Lothrop St., 8th Floor, Pittsburgh, PA 15213; 412-647-2200; fax: 412-647-5119; e-mail: noeckerrj@upmc.edu.
• William L. Rich III, MD, FACS, can be reached at American Academy of Ophthalmology, Governmental Affairs Division, 1101 Vermont Ave. NW, Suite 700, Washington, DC 20005; 202-737-6662; fax: 212-737-7061; e-mail: hyasxa@aol.com.
• Kerry D. Solomon, MD, can be reached at Storm Eye Institute, 167 Ashley Ave., Room 221, PO Box 250676, Charleston, SC 29425; 843-792-8854; fax: 843-792-6347; e-mail: solomonk@musc.edu.