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It’s breathtaking how much money some EMR systems cost. I’ve seen quotes for a seven-ophthalmologist practice that range between $250,000 and $380,000. That’s pretty astonishing for a piece of software.
So what happens if you purchase your system and you don’t like it? Most vendors will refund your money if it doesn’t work, or if there is some other failure to perform.* But they probably won’t give you a refund just because it slows you down and you hate using it. What then?
Your choices at this point are to…
1. Stop using it, curse the government for forcing you to get involved in EMR, and go back to paper (hundreds of thousands of dollars poorer).
2. Grin and bear it for every one of your patient encounters for the rest of your career, seeing fewer patients per day and spending your time chained to a system that progressively drives you crazy.
Clearly, either choice is horrible.
I’ve unfortunately met a few pioneering ophthalmologists who’ve purchased EMR systems and either uninstalled them or just stopped using them. Most spent over $100,000 on their system. They’d installed the software and hardware, tried to use the EMR with patients, and wound up going back to paper. Why? Their system looked good in the showroom, but it wasn’t useable in the clinic.
All of these poor docs had researched their systems, done the demos, visited competitors at conferences, and done all the due diligence that is possible for a busy eye surgeon to do. They had gotten references and tried out the system, and still they wound up with the big dollar disaster.
This is the scenario that keeps many of us from adopting EMR. The government is pushing us to spend huge amounts of money to buy an EMR system and use it in our clinics. They’ll pay us once to defray the costs, but if we choose the wrong one we’re stuck with it. Most of us have almost no experience using EMR systems in the clinic, and really don’t know what will work and what won’t. No one taught us in residency about networks and servers, or HIPAA security standards, or e-prescribing, or useability, or any of the many, many issues we have to sort out when deciding which system to buy. We’re being asked to lay down a huge amount of money for a system that will be hard to back out of if we choose the wrong one.
Pretty scary.
Fortunately, I think there are ways to avoid making a big dollar mistake like this.
The one thing I’ve heard in talking to ophthalmologists who’ve uninstalled or stopped using their system is that they did not choose it based on usability. Often they’ve let their practice manager or some administrator choose the system for them, or been swayed by “features” that they initially thought impressive or essential. They didn’t realize the importance of seeing how the system performed with patients.
When I’ve shown our EMR to colleagues, the number one question I get is “will it import data directly from my diagnostic machines?” Yes, it will, but that’s not the first question I would ask. In my opinion their question is valid, but the fact that they ask it first reflects their inexperience with EMR. After these guys have used EMR for a while I bet that won’t be the first thing on their mind. A year or two after using EMR they’ll be asking:
“How fast is it?”
Very soon after you start using EMR you’re going to have a waiting room full of patients who don’t want to wait. The lady in room three has talked your ear off and blocked the exit to the room as she told you about all eight of her grandchildren. You’ve finally escaped but you’re three patients behind and have several procedures coming up. That’s when you’re going to learn whether you’ve bought a good EMR or not.
Your EMR has to be fast. Not just faster than other EMRs, but faster than paper. Fast to learn, fast to use, fast for you, and fast for your staff. If it’s not faster than your current paper-based system you’re going to see a decrease in the performance of your practice, lower revenues, and patients who are unhappy they’ve been waiting so long. If it is faster than paper, you’ll be doing more ophthalmology, having more fun in the clinic, and you’ll see your EMR pay for itself.
So here’s my advice: when you are choosing an EMR system, don’t ask the salespeople to demonstrate the bells and whistles. Ask them to document a routine encounter with the typical patient you see. Tell them you don’t need them to talk, just document the encounter, code the visit, and sign the chart note. While they do this, time them. If they can’t document a routine encounter faster than you can do it on paper, don’t buy their system.**
There are of course other factors than speed. In my next blog I’ll be talking about some essentials of any system, like security, reliability, certification, interoperability, and flexibility. Most systems will satisfy these requirements, but usability is the single factor that separates the happy EMR user from the miserable one.
*You can view an example of a vendor’s money back guarantee at: http://www.nextgen.com/offers/guarantee.aspx. Notice that they guarantee performance, not satisfaction!
**I raced one of my colleagues on our system. We each documented an encounter with a patient with refractive error, cataract, and possible glaucoma. We created glasses prescriptions, entered an assessment and plan, ordered baseline glaucoma testing, coded the visit and signed it. The computer beat the pen 45 seconds to 51. I did this with a couple of vendors at ASCRS and no one came in under five minutes!
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We’ve all done paper charts. Most of us have done literally tens of thousands of them. They’re comfortable for us like a pair of old sneakers is comfortable. We’ve used so many of them we know exactly where to look for information, we have certain things we write, and our work habits are well established.
Making the change to EMR requires a little adjustment. Here are some tips to make the transition easier:
1. Charge right in. You won’t be able to review the chart before you walk in the room. This is unnerving at first. With a paper chart you can see why the patient’s there, review the patient’s interval history, and look at the data the technician has gathered prior to entering the lane. Unless you are using a tablet or iPad (I don’t), or you look at a computer in the hallway (which wastes time), you won’t be able to review the chart data before you go in. I’ve found this to be less of a problem than I thought it would be. I go right into the room, greet the patient, and ask how they are doing. I then review their note on the computer and go from there.
On our system, we print a summary of the patient’s continuing history (PMSHx, SHx, meds, FHx, allergies) which the patient updates in the waiting room if they have time. This sits in the old chart bin outside the room, so at least when I go in I know their name and some history. If your system supports this, it can help. If not, and you’re still uncomfortable with going into the room cold turkey, you could have a technician leave a small note in the bin with the patient’s name and a short sentence about why they are here.
2. Avoid talking to the patient while you are looking at the screen. When I walk in the room, I greet the patient in a general way, and then say “Let me pull up your chart.” I then log in, briefly review the technician notes, and turn to the patient to discuss how they are doing. I avoid talking to them while I’m looking at the display (those of you who have kids will know how annoying this is). I then complete the exam, discuss my findings and plan with the patient, and say “now let me make a few notes” and complete my EMR note. You’ll find your own strategy, but this works well for me.
3. Involve the patient. We have large 22” LCD displays in our rooms that everyone can see. The patient can see what I see and can see what I’m typing. I chose to do this for maximum transparency and patient involvement. This took a little getting used to because with the paper chart I was used to some confidentiality, first because it wasn’t displayed, and secondly because it’s hard to read my writing. Now that the patient can see everything, I love it. I find that they are much more involved in their care. They are more easily able to see and correct their medication list, I can show them images and drawings, and they see the complexity of what we do. They have confidence in what we’re doing and see that we’re not hiding anything. They also love the high-tech look of it.
4. Don’t buy a slow system. Make sure the system you buy is able to keep up with you. There’s nothing worse than having a patient about to get up and leave because you’re taking so long on the computer. The system you get needs to be at least as fast as the paper chart or you and the patient will be frustrated by the delays. Avoid systems with lots of clicking, multiple windows, slow response times, and overreliance on checkboxes. Web-based systems tend to be slower than local server-based ones, but if you do get a web-based EMR make sure you have a fast and reliable internet connection.
5. Maintain your equipment. Make sure your technicians know the startup and shutdown procedures for your computers and your EMR. You should never walk into a room and have to turn on the computer, open the EMR, or search in the EMR to find your patient. When you walk in you should be able to log in and have the patient right there on the screen with the appropriate data displayed. Similarly, your technicians should make sure that there is paper in the printer so you don’t run out in the middle of an exam. Posting standard procedures for startup, shutdown, and maintenance can eliminate frustrating delays when the patient is there.
6. Know your system. You’ve just bought your EMR, now it’s time to learn it. Just like in residency when you had to figure out a new paper exam template at a new clinic you went to, you have to figure out the layout of your EMR. Some are easier than others, but whatever you bought you need to learn. You can be the best ophthalmologist around, but if you sit there at the screen trying to figure it out with the patient in the room you won’t look like it. Kids figure out computers much faster than adults because they’re not afraid to get on them and try things. Play with your new system for an hour or so, entering some test patient data. It’ll pay off in spades when you are in your clinic. Barring that, have a competent tech or vendor rep be with you for your first few patients. Purchasing an EMR that’s easy to use helps too, of course.
The best way to figure out your routines when starting out is to start slowly and give it a little while. Get a good EMR and learn it well. Soon it’ll be part of your routine and you won’t look back.
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In the spirit of the season, I’d like to offer any physician with an EMR system our help in fulfilling one of the more difficult tasks of meaningful use. One of the tasks you will have to perform prior to achieving meaningful use is #14:
“Capability to exchange key clinical information (for example problem list, medication list, allergies, and diagnostic test results) among providers of care and patient authorized entities electronically.”
This criterion is one of the core measures for achieving meaningful use. To fulfill it you have to perform a test of your system’s ability to export patient information to a file, and upload it into another physician’s EMR system. The test doesn’t have to be successful, but you do have to demonstrate that you tried.
The hard part of this criterion is finding another physician with an EMR that is not the same as yours who is willing to try uploading the file you exported from your system. Most physicians still don’t have EMRs, and your local hospital may not either.
Here’s the easy way. Export a CCD or CCR from your EMR (your vendor can help you with this). Go to www.ccdccrviewer.com to upload your file. This is the way we view CCD and CCR files from within our EMR. Browse to the file and click Upload, then click on the button CCRTOHTML or CCDTOHTML as appropriate. The file will upload and then display in human readable HTML. If it doesn’t, don’t worry too much, because you’ve done your test and you fulfilled this criterion for meaningful use. Take screen shots and print them for your file in case you are audited.
Technical stuff: I think I’m the only practicing physician in the world who actually knows what a CCR and CCD are. I’m exaggerating of course, but if you ask around I’m sure you’ll find exactly zero of your colleagues have heard of these things.
CCDs (continuity of care documents) and CCRs (continuity of care records) are files that can be exported by all certified EMRs. They are ways to share information between EMRs sold by different vendors and at least theoretically provide some interoperability. In practice, they are quite cumbersome to use, and provide only limited information sharing. Most of the information they share is in the form of lists of medications, allergies, procedures, visits, labs etc. They don’t capture the subtleties of the physician’s plan or narrative notes, and have no graphical elements so you can’t use them to share imaging.
These files may become more important as time goes on and more physicians adopt EMRs. They do provide some capability to share information and upload it directly into another system. I’m dubious of the value of this, though. I personally would not want to upload information on a patient directly into my EMR in case some of it is incorrect or irrelevant. Ophthalmologists don’t need the same information in their EMR as cardiologists and vice versa. A better export format would have been .pdf, because we can all read those. Hopefully, as more of us use EMRs, CCDs and CCRs will fade away. For now, it’s good to have a passing familiarity with them.
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If you purchase an EMR system for your practice, and it allows you to see more patients, it will more than pay for itself, almost regardless of price. If it slows you down it will cost you an extraordinary amount over the life of your practice. For the typical comprehensive ophthalmologist, seeing one more or fewer patient per day will gain or lose the practice about $40,000 per year. For some retina specialists, that number may be closer to $90,000.
Let’s say you’re seeing forty patients per day. If your EMR requires one minute more to document an encounter with a patient than the paper chart, that’s forty minutes out of your day. In forty minutes you could probably have seen three patients. That’s about $120,000 your practice won’t realize this year.
Clearly, speed is king. When you look at EMRs, the question you MUST ask is: “How long will it take to document my encounters with patients?” If the answer is “Longer than it takes with the paper chart,” you shouldn’t buy it. If it’s faster than paper, though, it’s a great investment. The system will not only pay for itself, but will make your practice a small fortune over time.
We’re all busy, and it’s going to get busier. We’re facing a “perfect storm” of an aging population, more people with insurance, a relatively stable supply of eye doctors, and (probably) declining reimbursement for what we do. There will be plenty of demand for our services but we’ll probably be paid less per patient than we are now. Clearly, our ability to provide quality patient care to a high volume of patients will determine whether our practices prosper or fail.
Your charting system (paper or EMR) is the hidden determinant in how quickly you can see patients. That’s because you use it for every single patient encounter. Even a few seconds saved or lost per encounter gets multiplied by the number of patients you see per day times the days you work per year. Over the course of the year, thirty seconds per encounter can really add up.
Whichever charting system you use, it has to be fast. When I ask an EMR vendor how long it takes to document an encounter with a patient, “five to ten minutes” is not an acceptable answer (but it’s one I’ve heard over and over). When you look at whether it makes sense for you to adopt a particular EMR system, that needs to be the first question you ask. Forget the bells and whistles, speed is king.
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To EMR or not to EMR, that is the question…
Everyone’s talking about going to electronic medical records these days. What I usually hear from other physicians is “EMR’s coming, we’re going to have to do it.” The government is offering a sizeable bonus ($44,000) for adopting EMR, and eventually will penalize you if you don’t. But do you really have to do it?
The answer is no.
Are you surprised to hear that from someone who owns an EMR company?
A typical ophthalmologist will generate, on average, $150 per patient visit (retina docs can generate up to $400… I should have done a fellowship). When I calculate that over the year (including vacation time) each additional patient you see per day will bring in about $40,000 to your practice. That means that if you see one fewer patient per day, you will lose that amount.
A one-time $44,000 bonus from the government, or the additional 1-3% in Medicare payments you’ll earn for using EMR will not make up for seeing fewer patients per day. Clearly, if the EMR isn’t faster than paper, it isn’t worth doing.
Of course, if it is faster than paper, it doesn’t make sense not to adopt it.
- Kevin Cranmer, M.D.
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We are now listed on the HHS.Gov website as a certified EHR. Find More info here.
read moreODOS Industries, Inc. – ODOS – EMR 3.0
Certifying ATCB: Drummond Group Inc. | CHPL Product Number: 05272011-4860-8
Classification: Complete EHR | Practice Setting:Ambulatory
Additional Software Required:Dr. First Kalytta Character Set ConverterGeneral Criteria (170.302)
Ambulatory Criteria (170.304)
Ambulatory Clinical Quality Measures
Connect to the World of Ophthalmology in Orlando
Come share ideas, techniques and experiences with experts from around the world. The Annual Meeting is the most extensive scientific meeting for ophthalmology, covering all topics for both comprehensive ophthalmologists and subspecialists.
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EyeFormatics has received the federal government’s “meaningful use” stamp of approval by earning ONC-ATCB for Complete EHR and/or EHR Modules. The designation officially deems the electronic health record (EHR) software capable of enabling providers to qualify for funding under the American Recovery and Reinvestment Act (ARRA). Tested and certified under the Drummond Group’s Electronic Health Records Office of the National Coordinator Authorized Testing and Certification Body (ONC-ATCB) program, the EHR software is 2011/2012 compliant in accordance with the criteria adopted by the Secretary of Health and Human Services.
“The certification validates that our software can help providers take part in the electronic revolution that is reverberating across the healthcare industry. Healthcare providers can now leverage our software to not only make significant care improvements but to also achieve meaningful use and qualify for incentive funds under ARRA. We are proud to offer providers the opportunity to truly improve care in their communities,”
Drummond Group’s ONC-ATCB 2011/2012 certification program tests and certifies that EHRs meet the meaningful use criteria for either eligible provider or hospital technology. In turn, healthcare providers using the EHR systems of certified vendors are qualified to receive federal stimulus monies upon demonstrating meaningful use of the technology — a key component of the federal government’s push to improve clinical care delivery through the adoption and effective use of EHRs by U.S. healthcare providers.
ODOS Industries Inc., which met the requirements for ONC-ATCB, is a Complete EHR and/or EHR Module.
“The need to leverage information technology in the healthcare industry is huge – as the quality of care and efficiency benefits that come with computerization can really make a difference in the overall patient experience. We’re ready to help transform the industry by providing the sophisticated software testing services that ensure that vendors and hospitals are offering systems that are capable of meeting the meaningful use standards required to obtain incentive funds as well as the rich functionality required to move the clinical care needle forward,” says Rik Drummond, CEO of the Drummond Group. “We have been testing software for more than a decade and are ready to leverage our extensive experience handling sophisticated systems in complex industries as well as dealing with complicated technical issues such as interoperability and security.”
This Complete EHR or EHR Module is 2011/2012 compliant and has been certified by Drummond Group, an ONC-ATCB approved to certify any complete or modular EHR both ambulatory and inpatient, in accordance with the applicable certification criteria adopted by the Secretary of Health and Human Services. This certification does not represent an endorsement by the U.S. Department of Health and Human Services or guarantee the receipt of incentive payments.
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The Centers for Medicaid & Medicare Services have developed a very simply test to help you understand the eligibility requirements for the EHR incentive program.
Come visit us at the upcoming Wills Conference March 10th and 11th.
This is a three day conference designed for comprehensive ophthalmologists, specialists, and allied health personnel. The conference will review clinical, diagnostic and therapeutic approaches to eye problems related to all ophthalmic sub-specialties. In a didactic format, nationally recognized physicians will present the current trends in diseases and treatment options for cornea, retina, oculoplastic surgery, and other ophthalmic topics.
We will be located in the Bromley Claypoole room where we will have our software running live for anyone to demo.
Hope to see you there!
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