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EHR adoption draws mixed review
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Adoption of electronic health records by ophthalmology practices has accelerated in 2013. Ophthalmology was a bit of a laggard in embracing EHRs, as the early adopters were rarely happy with their experiences and discouraged many of us from engaging. On the other side of the equation was the carrot-and-stick approach of the federal government, offering financial incentives to place EHRs in our clinics now or face financial penalties in the future.
Most major academic centers selected Epic, and many ophthalmology departments struggled to adapt what is an excellent system for the internist and primary care physician to our field. Ophthalmology is a very visual specialty, and most of us who have practiced for decades fill our written charts with drawings and review images every visit, including visual fields, optical coherence tomography, fundus photography, topography, wavefront, specular microscopy and a plethora of other visual diagnostic tests. The outcomes of these important tests and our slit lamp and fundus examinations just do not translate as much information when described in words. In ophthalmology, one good picture is definitely worth a thousand words.
Our practice struggled, like most others, with these challenges, but driven by the knowledge that adoption of EHRs is a mandated necessity for a practice like ours, we implemented an EHR system this year at Minnesota Eye Consultants. We have 10 ophthalmologists, 12 optometrists and more than 200 employees ranging in age from 20 years to 70 years. We performed due diligence for more than a year on the programs available and in the end selected NextGen and a companion program called Symphony to display images.
While all the members of our team are computer literate, computer level, typing and data entry skills are widely variable. We began preparing for our go-live date 1 year in advance with numerous classroom-style and Web-based training sessions. We hired additional management staff and IT support personnel and, after much discussion, decided to provide each doctor with two clinical assistants/scribes while in clinic and one when in the operating room. Each of our doctors before EHR adoption had a single clinical support staff for managing patient logistics and counseling. All our surgeons work out of two rooms while in clinic, and we all disliked the idea of turning our backs on our patients as we entered data into the computer. Having a clinical assistant/scribe in each lane has allowed us to focus on the patient and maintain a personalized, eye-to-eye, high-touch clinical experience. While at first somewhat concerned that having a second person in my exam room during every clinic visit might create privacy issues, I have been pleasantly surprised that my patients accept it well and actually consider it a positive.
In our practice, all patients are seen by an experienced COT/COMT for preliminary history and examination. After this testing, the clinical assistant/scribe escorts the patient into the exam room, brings up the clinical chart on one large monitor and the appropriate images on a second monitor, and interacts with the patient while he or she is waiting for the doctor. In my clinic, wait times once in the room are never more than 10 minutes. I have found the patients rapidly establish rapport with the clinical assistant/scribe, and significant good counseling and question answering occur before I enter the room. I introduce myself, review the previously recorded findings, prior examinations and image findings, complete the HPI talking directly to the patient face to face, and then while examining the patient describe my examination findings out loud. I then explain these findings to the patient and family and discuss the diagnosis and treatment plan. All the while, the clinical assistant/scribe translates this verbal interaction into the EHR.
In some complex cases, a moment to help summarize the diagnosis and plan is required, but for most clinic visits, the experienced clinical assistant/scribe has no difficulty completing the chart. In the majority of cases, the EHR is sent to the referring doctor and primary care physician as completed, and I find myself dictating many fewer letters. I write almost no prescriptions for medications or glasses, both of which are handled electronically, although glasses prescriptions require a signature.
During the initial transition to EHRs, I reduced my clinic patient volume from six patients per hour to four, but after 1 month, I was back to six. Now, 3 months later, I find that I may be able to increase to seven or eight patients an hour. The rate limiting factor is actually the ability of the clinical assistant/scribe to keep up and not me.
A few thoughts and impressions at this early stage of EHR adoption. Incorporation of EHRs into our practice was very expensive and time-consuming, and I estimate we have spent more than $500,000 in the process. Our ongoing costs are also significant because each surgeon now requires two clinical assistants rather than one, at a cost of approximately $40,000 each per year. We also have one additional senior manager and one additional IT person. To date, we have not been able to reduce head count in other areas, but there is less dictation to transcribe. All of our doctors are back to our pre-EHR patient load, but no one as yet has increased their patients per hour. I think I can go up at least one patient an hour and maybe two, and in our clinic every patient translates into $200-plus in revenue, so if this works, it will be a positive on the revenue side.
In addition, documentation is better, and I suspect this will lead to more accurate coding. I expect this to be a positive, for most doctors tend to down code, and now the EHR will help us code as indicated. The enhanced documentation may also help protect us from medicolegal exposure, but knock on wood, our track record in that regard is already exemplary.
In regards to quality of care, I find it a tie from my perspective, but I expected it to be a negative. Patient satisfaction is high, they get as much or more attention from me, more from my extra clinical assistant/scribe, and they are impressed with the technology. I have no problem reading my colleagues’ notes, but there is a lot more to read.
So far, data mining has not been a positive, but we are early into the experience. Large groups, such as Kaiser, have made significant changes in their practice patterns, for example, switching to intracameral antibiotics in cataract surgery, based on mining their own EHR outcome data. I am optimistic in the future we will also have some positive learning experiences through analyzing our practice patterns and outcomes. Of course, third parties will also be able to mine our data, and it remains to be seen if the ultimate outcome of that process is positive or negative, but I expect the accountable care organizations of the future will only work with practices that incorporate EHRs, so we are now prepared for that eventuality.
The key agendas driving the mandate for EHRs are the government’s desire to increase access, increase quality of care, reduce costs and allow better data mining for regulatory and reimbursement oversight. So far on my report card, I judge access and quality of care the same. Cost is significantly increased for us, and I expect more accurate coding will also increase third-party payer costs, including the fees paid by Medicare and Medicaid.
In my opinion, this will be the unexpected consequence of EHRs. Their wide adoption will increase rather than decrease costs for everyone, including patients, doctors and third-party payers. To date, we have recognized no benefits from data mining, but our experience is early, and I am hopeful we and our patients will reap some benefits in the future. If not, all the government has done by mandating wide adoption of EHRs is further increase the cost of health care in America with no tangible benefit.