Strategies for Transitioning Today’s Ophthalmic Practice
Electronic Health Records (EHR)
Be Successful with EHR
Joseph L. Sokol, M.D.
Inside...
you will fi nd lessons learned by one ophthalmologist who successfully went paperless without going out of business.Copyright @2009 Compulink Business Systems. All Rights Reserved 800-456-4522 www.compulinkadvantage.com
Joseph L. Sokol, MD
When I launched my solo practice in 2006, after 11 years in group practice, I implemented electronic health records (EHR) from the outset. I’ve also watched my wife’s pediatric group practice go through a sometimes-rocky transition to EHR. Just as our phones, music, calendars and many other facets of life have gone digital in recent years, I believe the transition to EHR is inevitable—and that physicians who embrace it sooner rather than later will come out ahead.
Implementing an EHR system is a journey—and it’s one that certainly doesn’t end with the choice of a software vendor. In partnership with Compulink, I’ve put together these “lessons learned” as a resource for fellow ophthalmologists who may be just embarking on this journey.
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Lesson #1: There’s never a perfect timeBut now is a good time. There are federal government incentives for implementing EHR and, perhaps more importantly, the looming prospect of fi nancial penalties if you don’t. Starting a new practice with EHR is the ideal, but we aren’t all in that situation, obviously. Some other “trigger” events include: • Being in a smaller practice
• Needing to replace or implement a practice management system
• Wanting to bring billing in-house • Good cash fl ow – being able to afford it
I’ve talked to colleagues who want to wait until Medicare has perfected its requirements and everyone knows exactly what those requirements are. But we already know plenty about the direction Medicare is headed. It’s time to move forward. However, choosing a business partner who is stable, committed to meeting federal “meaningful use” requirements, and committed to the success of your practice is of paramount importance.
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Lesson #2: Change is scaryPeople are naturally resistant to change. Some are computer-phobic; others fear losing their jobs. Here are some strategies for getting the foot-draggers and naysayers on board with your plan to transition to EHR:
• Focus your energies on securing the cooperation of key providers and support staff – everyone else will follow suit. • Ask for input on how to make people’s jobs easier – that
way, you shift the focus away from a debate on the merits of EHR and toward how to get the best EHR system
• Empower staff In my practice, the front desk person designs our online intake forms, my chief technician works with Compulink on exam entry screens, and the biller takes the lead on reports.
• Be honest with clerical staff who might be displaced. Are there other roles they could fi ll?
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Lesson #3: There is no perfect EHR systemFinding an EHR partner is a little like fi nding a spouse – you are unlikely to fi nd every quality you desire in a single entity. So accept from the beginning that you will probably have to give up “perfect” and settle for “pretty darn good.”
When you start researching EHR, you might not even know which features you really need, so start with a broad wish list of what you’d like to have. For me, the wish list included fi nding a system that was part of an integrated, overall practice management system, could be modifi ed or customized, would interface with my examination equipment, had mail merge and word processing capabilities for generating letters, and had E-prescribing capabilities.
As you educate yourself, your list of “features I absolutely must have at any cost” will likely evolve. Here’s the EHR necessity list I came up with:
• “EHR that is part of an integrated, overall practice management system” stayed on my list. I needed the whole package and wanted it to all work together. If you want to keep an existing PM system, fi nding an EHR system that can interface with it (and a vendor who has a track record of making that work) is a necessity.
• Easy to learn and use. No matter how impressive its capabilities, if a system seemed overly complex to me or other users reported that it was tricky to learn, I crossed it off my list.
• Able to access remotely
• Forwards data easily from previous examinations
• Can easily create and save scripted blocks of text for common assessments of symptoms, treatment plans, and recitation of risks and benefi ts.
• A scalable system and a stable vendor that could grow with my practice
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Lesson #4: Get advice—and lots of it!Early on, fi nd someone you know personally and trust who uses an EHR system successfully. You may not choose the same system as your mentor (I didn’t), but their advice will be an invaluable starting point. Other sources of advice:
• Ask vendors for references and call several for each • Ask members of your state and local ophthalmology societies
• Query colleagues at section meetings at the local hospital, • Remember, the most valuable advice will be from practices
that are similar to your own.
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Lesson #5: Do your homework so you pick the right EHR partnerI know it seems like a hard thing to ignore, but don’t let cost be a major factor in your initial comparison of EHR vendors. Use
Table 1 to rank potential vendors on some basic questions as you start winnowing the list.
Finding an eye-care specifi c system is absolutely critical, because ophthalmology (and optometry) are so unlike the rest of medicine. We have our own set of “systems” and our own eye codes. We often have a retail component to the practice in the form of an optical shop. And we provide a unique combination of in-offi ce and surgical care. In short, trying to modify a general medicine EHR for eye care can be frustrating.
I was also interested in the quality of the relationship I would have with my EHR vendor. I wanted to be able to talk to real people who would support my practice growth and I wanted to feel confi dent that the company offered excellent training and support. You can get a feel for how responsive the company is to your initial queries, but you must ask current users about these qualities.
A major reason I chose Compulink was that it had a long track record (15+ years) of EHR planning and management expertise, as well as one of the largest bases of installed users in eye care. In all those years, other users have helped refi ne the software – which meant fewer bugs for me to deal with.
Testing the options yourself is critical. You will probably need to do all these things, in this order, but the most helpful step is the last one, so don’t skip it.
1. Go to trade shows to see multiple systems at once. Remem-ber, sales people are uniformly enthusiastic, personable, and expert at navigating their own systems.
2. Get demo disks and try the software at home. Does the disk run? Enter a few records. Is it as easy to navigate as the sales person made it seem?
3. Arrange for on-site sales demonstrations.
4. After you narrow your list, visit similar practices that are using the system(s) you are considering. There is absolutely no substitute for observing a system in action
Intial Vendor Comparison 1 2 3 4 5 6 7 8 9 10
Independent business (I) or Subsidiary (S)?
Look for autonomy and stability
Years in business (#)
Look for longevity!
Eye care focused? (Y/N)
# of installations?
How many practices are running the software now? I saw some very appealing systems with very few users. Don’t be a guinea pig.
Customer support hours?
You need support during your business hours, even if the vendor is in a different time zone.
Responsiveness and “feel good” factor (Y/N)
Meets my wish list goals
Use the rest of these lines to rank how well the software meets your specifi c goals for integration, customizability, ease of use, etc
Table 1:
Finally, look at the numbers. Only after you settle on a short list of 2-3 systems you like should you really see how they compare on detailed pricing, using Table 2.
A lot of people are afraid the costs of EHR will be astronomical, but they need not be. In thinking about your total cost, don’t forget to factor in anticipated savings in personnel costs, reclaimed offi ce space that can be put to more productive use than to store charts, and lower supply costs. Also, don’t forget that not acting on EHR will cost you, too—in the form of reduced Medicare reimbursements and patient perceptions that your practice is outdated.
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Lesson #6: Give yourself enough time to do it right So now that you have an EHR vendor, when do you actually put the system in place? In a new practice, implement the system before you even open the doors. But for most doctors in established practices, choose a slower time of year. You can also consider phasing in implementation to minimize the decrease in production or spread it out over time. For example:• Roll out modules one at a time • Transition one offi ce at a time
• Have a few providers at a time switch to EHR
Your goal should be to implement smoothly without letting EHR take over your life. I spent a couple months researching systems, made my decision in June and scheduled the actual implementation for October. A large group may need even more time to work out the details, customize their system, and schedule enough practice time (See lessons #7 through #10!).
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Lesson #7: Think through the detailsOnce you’ve gotten through the big-picture decision, “I’m moving to EHR!” there are a lot of details to work out, well beyond the choice of a vendor. I’m going to break this down into two main “detail” areas, in roughly the order you’ll need to deal with them.
Patient fl ow
Sit down with physicians and staff and talk though the entire patient fl ow, from the time the patient calls to make an appointment, to checkout and scheduling of follow-up ex-ams. Figure out how every paper-based process will now work electronically. Put the plan in writing and add notes to it for a week or so as you see patients.
• What information is entered when the patient calls in for an appointment?
• Who enters the history and when?
• How does the patient get from place to place in the offi ce? • Where will computers and printers be located?
• What willthe doctor/technician see on the summary screen? • Who should have which permissions?
• Will exams be entered in real time? By the doctor or a scribe? • When and how will the doctor sign off on the record? • Will you use a keyboard, tablet, or other mechanism in the
exam room? Think about positioning.
• Will there be a superbill? What will the patient take with them to checkout (if anything)?
Price Comparisons Vendor 1 Vendor 2 Vendor 3 Initial Outlay
System licenses (may be per practice, per user, or per physician) Training and implementation
Data conversion
Hardware (new workstations, server upgrades, etc) Interfaces (to connect devices, cameras, etc. to system) Extras (E-prescribing or other modules, customization, etc.)
Recurring Costs
Annual support
Billing (per-claim processing, clearinghouse access, etc.) Post-implementation training or customization
Future Costs
Understand impact of practice growth
Table 2:
What to do with all those paper charts
In a startup practice, I didn’t have to worry about a room full of old charts, but I still had many patients who followed me from the previous practice, and brought their charts with them. I chose to review each chart and summarize the history in the electronic record. I told staff which tests to scan in and directed them to return the rest to the patient. There are lots of options for how you may choose to handle paper charts:
■ Physician does chart review and summarizes the history (as I did)
■ Scan old records • Everything? • How much?
■ Enter previous visits into the system as data • Defi ne key parameters
• Enter last X# exams
• Enter or scan in these 10 key facts for a glaucoma pa-tient, these 7 for a cataract papa-tient, etc.
• Have support staff enter uncomplicated records, set “complex” patients aside for physician (you will have to de-fi ne complex)
■ Keep the chart and refer to it? Be warned: Trying to use both is unwieldy and opens up temptation of not using the EHR. ■ In an established practice, you’ll have to decide whether
you will convert all active paper charts at once (could be overwhelming) or only those scheduled for the next day/ week/month.
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Lesson #8: Customize your systemHopefully, you’ve chosen a system that is geared toward ophthalmology and fl exible enough to be customizable to your own practice needs. This was a major reason why I chose Compulink. I was able to start using the system “as is,” but I always knew that anything I didn’t like could be changed.
Decide how much, if any, customization you need to do to the system in advance. I personally thought it was a waste of time to make the testing and exam screens look exactly like a paper chart, but others may fi nd that is the only way to achieve the same productivity or secure the acceptance of key people. More customization will make you more effi cient. For example, the more pre-scripted assessments and plans you add, the faster it is to drop those into the exam when you see a patient. But expect customization to be an ongoing endeavor, and don’t spend months making the system “perfect” before you even start using it.
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Lesson #9: Prepare, prepare, prepare!There will be chaos and confusion when you fi nally “go live,” but you can minimize the stress and lost productivity by being well-prepared. Practices that invest the time on the front end are able to get back to normal patient loads much faster.
A clear plan for all the issues in the section above (“Think through the details”) is an excellent start. You should also fi nd local IT support early in the process. This is not a huge expense and it doesn’t mean you have to hire an IT department.
There are many local computer service companies or computer-savvy individuals who can troubleshoot hardware or network problems and can work with your EHR vendor during the transition to make sure all the little pieces are working as they should.
Assembling and preloading data, testing hardware, and entering or scanning old charts is critical, along with “dry run” practices and debriefi ng sessions for everyone who will be using the software. For a checklist of specifi c tasks that can be performed in advance, see Table 3.
Pitfalls to avoid
• Getting too complex a system. If it has great capabilities but you just can’t make it work, the transition will be a disaster.
• Overthinking. Don’t spend so much time customizing a system that you delay starting to actually use it.
• Inadequate training. In the grand scheme of an EHR implementation, training is cheap. Don’t skimp on it.
• Incomplete physician or administrator buy-in. • Poor local IT support.
• Trying to convert with a regular schedule. • Continuing to use paper.
• And of course, the most expensive pitfall of all is abandoning ship entirely because you just can’t integrate the system into your practice. That’s why it pays to do your research up front and select a partner with the ophthalmic EHR expertise to see you through the transition successfully.
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Lesson #10: It is not possible to get too much training! In fact, if I have any regrets about my own EHR implementation, it is that I didn’t schedule more post-implementation training. Defi nitely take advantage of cost-effective online training resources. With Compulink, recorded courses are free and are a great way to get started, brush up on a topic or bring a new staffer up to speed.Live training can be individualized for different personnel or departments. After you have used a system for a period of time, additional training can be very helpful in identifying more effi cient approaches and pointing out under-utilized features. And most importantly, you’ll have very specifi c and insightful questions that you would never have known to ask in the confusion of the initial conversion to EHR.
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Lesson #11: Be clear on who does whatMake sure you understand what the vendor will do and what you and your local IT support people need to do. Don’t assume, for example, that your insurance card reader or camera will automatically connect to the EHR system. They won’t - unless you have specifi cally connected and tested them in advance. Compulink offers a range of installation options, from sending you just the software discs to load onto your system, to
providing the hardware and software ready to go, to hosting the system on their own servers and providing you with secure, Web-based access. Make sure you understand who is doing what, when they will do it, and what additional charges you may incur.
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Lesson #12: You will get better at it – I promise Pare down your schedule for at least for the fi rst few weeks after implementation. Some practices handle this by spacing appointments further apart; others see patients in the morning and leave the afternoons for troubleshooting, debriefi ng, etc.Expect to be befuddled! You’ll get the hang of everything… but not the fi rst day or even the fi rst week. Resist the temptation to do both paper and paperless exams in parallel. People will naturally fall back on what is more comfortable, prolonging the transition. It helps to let patients know what you are doing and why, either with signage or verbally.
The key thing to remember during those challenging days in the fi rst weeks or months is that creating an electronic record is not your goal—it’s merely a necessary step toward your goal. The real goal is the effi ciency that comes with the second visit (and the 3rd and 4th) when you can see everything at a glance, forward information from the previous exam and just amend your fi ndings. If you can push through the initial work, every subsequent visit will become an easier one.
EHR Preparation Checklist
Task Individual Responsible Target Start Date Target End Date Done?
Assemble and pre-load data into the system’s database
Tables
Referring physicians Frequently used codes
Cities and ZIP codes for patient base Common medications
Insurance plans Pharmacies
Secure local IT support
Decide placement of computers, printers, etc Purchase hardware
Install hardware Test hardware/network Schedule backups Convert paper charts?
Arrangements made for offsite chart storage Arrangements and protocols for offsite backups Customize screens
Customize drop down lists
Task
Table 3:
The easy and immediate benefi ts
• Access to records after hours, off site, wherever you are • No lost charts
• No costs of buying, storing, and manipulating paper charts • Simultaneous access because multiple people can interact
with the patient’s record without physically moving it
Medium-term benefi ts
• Legible, complete records that are more likely to be compliant with the service codes you bill
• Easier to track patient tests and to store testing within records
• Enables cost-effi cient in-house billing • Quick generation of referral letters
• Easy to gather statistics and run productivity reports
• Easier to mine data for outcomes analysis, research or marketing purposes
• Ability to educate patients with easy access to photos and diagnostic images on the screen in the exam room.
• EHR makes a statement about you as a technologically advanced provider who invests in his or her practice. Patients and referral sources will perceive you as ordered, accurate, and ahead of the curve
• Security - you are more likely to recover relatively intact from a data failure than from fl ood or fi re damage to your paper records
• Track and follow-up on laboratory tests more precisely • Remind yourself to follow up on patient complaints or
problems after visits
• Accurate medication lists and better awareness of drug-drug interactions
Big-picture benefi t
Although harder to quantify, the ultimate benefi t of EHR is providing better medical care. With EHR, it is easier for you and for other providers to quickly grasp what is going on with patients. It is more straightforward to understand their medical histories and the impact of past interventions and to determine whether diseases are progressing. It is easier to develop treatment algorithms that let you practice more scientifi cally and less anecdotally.
That’s a future we can all look forward to. Dr. Sokol is in private practice in Shelton, CT. Contact him at (203) 926-1700 or [email protected].
The benefi ts of EHR
from an ophthalmologist’s perspective
This is what it’s all about, right? There is a reason I implemented
EHR and a reason you’re going on this journey. Maybe you’re just sick of tracking down charts in multiple offi ces. Maybe a junior partner is dragging you down this path. Whatever the reason you have embarked on this journey, here are some of the benefi ts that you’ll gain, as I see it:
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