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    Electronic medical record debate presents benefits

    Discussion highlights some shortcomings, especially in regard to customized programs


    The adoption of electronic medical records (EMR) in the United States has been slow, but interest seems to be picking up despite a number of obstacles.

    While debating the extent to which EMR truly can benefit an ophthalmology practice, Michele C. Lim, MD, suggested that EMR can improve patient safety and quality of care, offers financial benefits, and can maintain or improve personal and professional quality of life, whereas Harry A. Quigley, MD, countered that EMR does not yet work, slows providers down, costs more than they save, and invents new ways to make mistakes.

    Opening the discussion, Dr. Lim, associate professor of ophthalmology, University of California, Davis, Sacramento, said that features of EMR that could improve safety and quality of care are instant access to patient information, the elimination of illegible handwriting, improving communication with other health providers or patients, and reducing medical errors and adverse events.

    Half of serious medication errors are related to insufficient patient or drug information, while e-prescribing—ordering medication within EMR—can provide several safety stops, Dr. Lim said, such as alerting providers of allergies, errors in dosing, or drug-drug interactions.

    Dr. Lim also said that although a system is costly to implement, evidence shows that a return on investment can be attained.

    Research in primary care outpatient settings indicated that on average, practices took 2 years to pay for implementation and subsequently realized a $23,000 net benefit per provider per year. Benefits are derived from higher productivity and an associated decrease in personnel costs, greater revenue capture per physician through more accurate coding, reduced transcription costs, space savings, and a decrease in adverse events.

    Dr. Lim also discussed the results of EMR implementation at the UC Davis Eye Center, which went live in November 2007. A productivity assessment found better tracking of documentation, more legible notes, and more complete documentation, since physicians were motivated by the EMR system to write more thorough notes.

    A detailed analysis of subsequent revenue gains looked at the number of CPT codes billed per patient, per year, which is an indirect way of looking at charge capture per patient.

    "We concluded that revenue increased after the EMR implementation because of increased charge capture," Dr. Lim said. "Increases in patient volume and the number of imaging procedures performed were also observed."

    Faster than paper

    Dr. Quigley, the A. Edward Maumenee Professor of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, was more critical of EMR but also commented on several positive aspects of a system custom designed for his group.

    "The problem with EMR is that the guys who write these things don't realize that it can't just be translating your paper chart into an electronic chart because that costs too much, it's too slow, and it's useless. It has to be faster than paper," Dr. Quigley said.

    The learning curve associated with adoption of EMR should not stop a practice from considering it, he added, since this phase is typical when learning anything new, as long as EMR ultimately results in seeing patients faster and with greater quality.

    "But I posit to you that there is no commercially available system that presently does this," he said.

    Features he said he would like to see in a system include a minimum number of keystrokes and instantaneous movement from one window or event to the next, the availability of all information on single screens as much as possible, macros for repeated data entry, and the ability to carry forward information, provided the system prevents "cheating" by falsely claiming to have done exams.

    Dr. Quigley also suggested that all programs should have a summary page. The ideal first screen on an EMR system in a glaucoma practice would include the patient diagnosis, highest previous IOP (untreated), previous and present treatment, a list of risk factors, the target pressure goal, the plan from the last visit, today's pressure, and vital information (such as optic disc photographs, visual fields or visual field progression data, results from imaging devices, and a graph of IOP history, updated at each visit). The screen also should include the risk-progression ratio, visual acuity data, and the patient's demographic information and medical history.

    "In one screen I know what I want to do today," Dr. Quigley said. "I know the patient's history, and I can start spending time talking to my patients about them and who they are and how they're doing."

    Another shortcoming of current EMR programs is that they fail to take into account the time technicians spend with patients before they are seen by physicians. The technician portion and the physician portion of the visit are not necessarily a continuous patient record but need to be integrated so that the technician's readings for pachymetry, visual fields, and other data are available by the time the physician sees the patient.

    "We need to analyze data, not to have it in a stack of paper; and to be able to analyze it, we need it to be in good, useful, immediate form," Dr. Quigley said.

    He also said that the benefits of EMR have been demonstrated academically in only four institutions, all of whom developed their own systems, an option that is impractical or impossible for many practices. Groups within large institutions are likely to meet tremendous resistance from administrators who want to "shoehorn" ophthalmologists in with other specialists and assume that it's no problem for everyone to use the same EMR format. Dr. Quigley added that even within ophthalmology subspecialties, the requirements differ, because a retina note is not the same as a glaucoma note.

    Other concerns are whether companies that develop and sell EMR systems still will be in business several years from now, and what will happen if they're not, as well the systems' security.


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