Like most medical specialties, ophthalmology has unique needs when it comes to electronic health record (EHR)...
Since so much of ophthalmology is visual, little emphasis is placed on vital signs and traditional disease diagnostics. Instead, practices need EHR systems that support freehand drawing, integrate with imaging systems and transfer data to eye surgery modules.
Diagnoses depend on fast access to imaging studies and patient data such as visual acuity and corneal pachymetry, said Flora Lum, M.D., executive director of the H. Dunbar Hoskins Jr. Center for Quality Eye Care. Clinical documentation capabilities are less important, partly because of the visual nature of ophthalmology and partly because of the field's high patient volume.
In this regard, most ophthalmology EHR software is rather limited, she said. It also explains why the handful of systems that appear on the Certified Health IT Product List -- systems which must be used to demonstrate the meaningful use of EHR -- are the exception rather than the rule.
Meaningful use objectives too few and far between…
For physicians participating in stage 1 of meaningful use, attestation means meeting all 15 core (required) criteria and five of 10 menu (optional) criteria.
Specialists can meet meaningful use by claiming exceptions to requirements that do not apply. They can do this by reporting as zero the numerator and denominator for an irrelevant criterion -- using e-prescribing to order medications, for example.
In addition, meaningful use attestation requires eligible professionals to report on three (of six) required and three (of 38) optional clinical quality measures. Many optional criteria focus on treating cancer, diabetes or heart disease and, as a result, do not apply to certain specialists.
As one example, ophthalmology EHR software vendor ManagementPlus notes that its system has been certified to meet the six required quality measures but only three additional measures:
- Tracking patients diagnosed with primary open angle glaucoma
- Tracking patients diagnosed with diabetic retinopathy
- Giving diabetic patients a retinal, dilated or negative retinal exam
(A fourth quality measure pertaining to ophthalmology tracks the frequency of "documented communication" with a primary care physician regarding the results of a diabetic patient's dilated macular or fundus exam.)
Therefore, Lum said, it's quite possible for ophthalmologists to achieve meaningful use without seeing real improvements in efficiency or care quality.
…not to mention too basic?
Lum and 10 colleagues outlined ophthalmology's special EHR requirements in a June 2011 Ophthalmology magazine article (registration required). Chief among the issues are a lack of interoperability with imaging systems, innumerable proprietary data formats, cumbersome user interfaces and data entry fields that do not support the specialty's clinical documentation needs.
Most of the data that ophthalmologists need during a patient visit is not likely to be in the EHR system itself. Health information exchange with, say, an eye surgeon is equally unlikely. Supporting such functionality requires an investment beyond the means of many ophthalmology EHR software vendors, Lum said.
Moreover, such functionality is beyond stage 1 requirements. To provide data exchange that's truly beneficial, ophthalmology EHR software would have to support numerous clinical documentation standards. Ophthalmology specifically listed the following:
- Systematized Nomenclature of Medicine -- Clinical Terms (SNOMED CT)
- International Classification of Diseases, Tenth Revision (ICD-10)
- Digital Imaging and Communications in Medicine (DICOM)
- Health Level Seven International (HL7)
- Integrating the Healthcare Enterprise (IHE)
Stage 1 of meaningful use, on the other hand, focuses primarily on documenting patient information and simply testing, not necessarily using, HIE technology.
Most of the data that ophthalmologists need during a patient visit is not likely to be in the EHR system itself.
Stage 2 and 3 meaningful use criteria, which should be finalized in early 2012, will be key, Lum said. In the meantime, she added, the American Academy of Ophthalmology is ramping up its advocacy efforts -- making a routine eye exam template part of health information exchange, continuing to push for DICOM adoption and working with other medical specialties to identify more relevant quality measures.
Implementing ophthalmology EHR software means addressing workflows
Today, though, ophthalmologists can achieve meaningful use and receive federal incentive checks. Much like EHR implementation, meaningful use attestation requires advanced planning. As Ophthalmology Management magazine pointed out, the process is equal parts getting to know the meaningful use criteria and getting to know where entering (and retrieving) the data needed for meaningful use attestation fits into a practice's clinical workflow.
That can be tricky. During a patient encounter, different data is collected by different people at different times. Outlining an ophthalmology EHR software meaningful use workflow, as EHR and medical practice management software vendor SRSsoft has done, can help a practice determine which data should be collected by front desk personnel ,a medical technician, an ophthalmologist or the practice manager. Establishing this workflow can also help a practice identify exclusions.
The time it will take to get clinical workflow analysis right provides yet another reason to proceed with caution. Ultimately, implementing ophthalmology EHR software represents a tremendous shift in how a practice operates. The financial and care quality benefits are there, but only if a practice is ready for the challenge.
One practice's lessons in implementing ophthalmology EHR software
The Eye Center of Central PA was one such practice. Based in Lewisburg, Pa. with 13 locations across the state, the Eye Center began implementing its ophthalmology EHR software from Medflow in the spring of 2010.
Three steps in particular allowed the practice to adopt EHR quickly and without a single employee resigning.
- First, the Eye Center made sure to prove the success of the system at its primary clinic before proceeding with EHR implementation at its surgery center, where up to 50 cataract procedures are performed daily.
- Second, physicians were convinced that the software would impact the practice "much more than any single device or surgical tool," partner Scott Hartzell, M.D. said in a case study.
- Third, training began several weeks before the go-live date, which eased the learning curve for end users once the EHR system was in fact up and running.
With the ophthalmology EHR software in place, the Eye Center -- which received its meaningful use check on May 25, 2011 -- is spending less than an hour a day pulling patient charts, is submitting billing claims the same day as a surgery, and is collecting on claims in 28 days, compared to 45 days before using EHR. "Information now comes to us rather than us having to go to it," Hartzell said in the case study.
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