Getting Senior Staff to Embrace EMR

Ophthalmologists nearing retirement may find EMR adoption more advantageous — and easier — than they’d thought

Getting Senior Staff to Embrace EMR

Ophthalmologists nearing retirement may find EMR adoption more advantageous—and easier—than they'd thought.

By René Luthe, Senior Associate Editor

Ophthalmology has always been a high-tech field, and its practitioners are eager to adopt the newest technologies. But attitudes toward electronic medical records run counter to that perception: many approach the task of converting to EMR with more dread than enthusiasm. And some older physicians believe they can simply “wait it out” a few more years until retirement. It's not that they can't see the advantages of EMR; to them, the headaches—including a formidable price tag and the frustrations and reduced productivity involved in implementation—outweigh all else. Sure, beginning in 2015 they'll have to take the federally imposed penalty of a 1% or 2% reduction in their Medicare reimbursements, but that's still cheaper and easier than completely abandoning the way they've practiced medicine for decades. Let EMR implementation be the responsibility of their successors. To those looking for an “out,” it sounds appealing.

A common objection among physicians of any age is that having to enter data into a computer distracts them from focusing on their patients; others complain that the required typing feels like clerical work, and hence is not the best use of their time. Whatever the reason, the deadline for adopting EMR and avoiding the 2% Medicare penalty is drawing nigh (to qualify for the promised federal incentive money of up to $44,000, a practice would have to implement EMR by the end of this year). Even if you think you would rather take the financial hit and ride off into retirement, the decision could hurt you when it comes time to sell your practice. Experts swear it's worth the trouble. And to help the inevitable go down more easily, they offer their tips for successful, low-stress EMR implementation.

Eyes on the Prize(s)

The advantages of EMR adoption have been enumerated elsewhere, but a recap from real-life implementers may kindle your enthusiasm.

Stop drowning in paper. The ability to eliminate, or at least greatly reduce, the amount of paper in your practice is “a powerful draw,” according to Jorge Mirabent, practice administrator and chief operating officer at Aran Eye Associates in Coral Gables, Fla. “We are a very large practice, and the paper was just overwhelming,” he says. And because they have remote offices, they had to transfer charts back and forth before adopting an EMR system. Now, of course, any chart can be pulled up on a computer screen at any location.

Joy Woodke, COE, OCS, administrator at Oregon Eye Consultants in Eugene and a member of the AAOE's committee on electronic health records, reports that the absence of paper goes beyond just having less clutter: the practice reclaims valuable office real estate.“We were able to add a few more work stations and to give desks to a few people who had been floaters.” The practice also was able add staff lockers, “which was a huge morale booster,” Ms. Woodke says.

Get better charting. EMR also makes charting more complete and accurate, according to Linney Patton, COE, administrator at Gold Eye Clinic in Palestine, Tex. Poor handwriting is no longer an issue in trying to determine what was done, an especially important factor in the event of a Medicare audit, and EMR programs catch billable services that were formerly sometimes lost to human error. Additionally, EMR has simplified the audits his practice undergoes from Blue Cross & Blue Shield. “They have high praise for our records,” Mr. Patton says. “They say it makes their job easier.”

Increase your practice's value. The desire to increase the practice's resale value is another reason that Mr. Patton's physician-employer took the EMR plunge. It's an especially important point given the forecasted physician shortage in the coming years. According to a report by Keith Borglum, CHBC, CBB, of Professional Management & Marketing, while past generations of ophthalmologists enjoyed a large pool of potential successors, and hence bargaining power, “today there are a lot more jobs than applicants.”

While retiring doctors often hope their buyer will be the one who takes on EMR implementation, its absence could be a deterrent in what will ultimately be a buyers' market. Older physicians, who are usually more financially stable, may be willing to take the hit in Medicare reimbursements, but new physicians are less stable, Ms. Woodke points out, and will not want to shell out the considerable sum for an EMR system and deal with reduced reimbursements—as some may also be struggling to repay student loans. And in a practice market where there are more sellers than buyers, they won't have to.

“A practice that is running efficiently, has electronic charting, is capitalizing on PQRI and e-prescribing incentives and is on track to gain EMR meaningful use payments is going to be valued higher than that of the practice that is still using paper charts and not moving forward with technology,” Ms. Woodke says.

No regrets. “When we ask our staff if they would ever go back to a paper chart, there's not a single staff member who says yes,” Mr. Patton reports. “They all say no!”

Back to School

Finding out just how familiar a practice's physicians are with computers and checking that against the computer skills they will need to operate your EMR program will save your practice considerable time and frustration.

Ms. Woodke's practice implemented basic computer skills training before even beginning the training for their new EMR. They started by creating a list of skills they believed would be necessary for anyone using a computer. “We assessed their skills with pop-ups, pasting, minimizing, maximizing—the simple, basic computer skills,” she explains. “We checked if they knew how to bring up a software program, how to maneuver around, and so on.” Training sessions were offered to each employee based on their individual assessment.

When Ms. Woodke realized that with a new software system came new computer terminology, the practice created an EMR dictionary for the terms that were important to operating their system. When EMR implementation began, the practice then knew that all staff—physicians, techs and front office personnel—were sufficiently computer literate.

One Piece at a Time

Once doctors are armed with the skills they will need to use the practice's EMR, is it time to jump head-first into the digital age? Probably not. An approach shared by those who have been successful with EMR implementation is that of going, in the words of the classic Johnny Cash song, the “one piece at a time” route. This could mean starting with just one physician in a multi-doctor practice, one type of patient or one EMR feature.

Ms. Woodke reports that her practice began with the Rx refill and the triage system. “We didn't implement charting of patient encounters yet; we were just using a piece of the functionality, one that was fairly simple. It also allowed them to refine their typing skills,” she explains. Once everyone was comfortable with those, they moved on to another feature. “We also taught simple processes like opening charts. We called them ‘building blocks.’ Like anything you'd learn in school, we first taught them something simple and then we would build on to it.”

Mr. Patton's practice went with another variation on the bite-size approach. Rather than attempt to scan all their old records into the EMR, something many of his colleagues were doing, he made the decision to start with new patients only. “Everything else was entered on paper, as usual,” he says.

When everyone had become comfortable with the process a few days later, they added glaucoma follow-ups. Again, once those patients were incorporated into EMR and doctors and staff were confident, another patient group was added to EMR.

“With the established patients, we pulled the chart for that initial visit and we would flag it. We wrote ‘EHR’ on the front of it, and the doctor knew that if there's anything he wanted out of that chart, he would flag that and we would scan just that information. If he didn't flag anything, then the chart went to storage and we didn't pull it any-more,” Mr. Patton explains. Within approximately a month, he reports that the practice was doing all patients EHR, and didn't pull charts after one year.

Mr. Mirabent's practice took it doctor by doctor. They also trained the staff that was with that doctor at the same time. “We rotate our doctors through our satellite offices,” Mr. Mirabent says, “so as the doctor went from one office to another to another, staff at each were trained too; all the offices kept getting implemented. We got a blend of both doctors and offices rolling out.”

The Scribe Solution

Besides dread over the technological headaches they expect EMR to bring, many doctors resist because they don't like the idea of having to focus on a computer when they need to concentrate on the patient in front of them. The answer, according to many practice administrators, is scribes. Janna Mullaney, of Katzen Eye, says it is a commonly voiced concern among the practices that visit her each month to observe their EMR implementation. “They say, ‘How am I going to keep my face-to-face time when I constantly have my back to patients, entering information into the computer?’”

Scribes, she says, both allow the doctor to focus on the patient and increase productivity. She believes their cost can be offset not only by the extra patients they allow the practice to accommodate, but also by the reduced need for transcription services. “Documentation is better, you can usually better support your exam code, and I find you don't miss little ancillary things like punctal plugs or tests that were done,” Ms. Mullaney explains. The resulting savings help to offset some of the cost of the scribes. “And you can usually add a patient or two in the morning and a patient or two in the afternoon.”

Ms. Woodke also finds that scribes increase efficiency as well as allow the physician to concentrate on the patient. Prior to EMR, the doctor would escort the patient to the front desk and verbally instruct staff when to schedule the next return visit for the patient, etc. Now, Ms. Woodke says, when the doctor finishes with one patient, he goes on to the next exam lane and begins his assessment. The scribe completes the EMR of the first patient, sends the electronic order for that patient to the front desk, sends that patient out and then joins the doctor with the second patient. The increased efficiency allowed the practice to eliminate 1.5 full-time employees, she reports.

While physicians who have never had scribes worry about their cost, Ms. Mullaney says that often when they visit her practice and observe the interplay between the doctor and the scribe, that the scribe records even the doctor's conversation with that patient, they are swayed.

Mr. Mirabent, however, is still unconvinced. For smaller practices, he views scribes as a luxury. While the doctor's assistant in the exam room can assume scribe duty if not otherwise engaged, a dedicated scribe will almost certainly be a drain on the bottom line of a one- or two-doctor practice. “You can make the argument that you pay for a scribe by eliminating other positions, but will you do that?” he asks. “Generally what happens is that you redeploy those people because they are decent employees and you would rather not fire them or you can use them better elsewhere.”

Other Tricks and Tweaks

Another common complaint about EMR is the rigidity of the templates; doctors often feel that the system is driving the way they practice. “That's usually what everybody hates,” Ms. Mullaney says. “They say, ‘But I don't do it this way!’” To eliminate this obstacle, she believes that a system that allows modifications is essential when incorporating EMR into a busy practice.

The post-it notes that techs could stick inside the chart flap to remind physicians of important information about a patient before they entered the exam room don't have to be lost when moving to EMR, Ms. Mullaney points out. Some programs allow “pop-up” boxes in the patient's file for such reminders. The ability to put a patient's photo in the EMR is another help for many physicians, she finds.

“Doctors have told me that they are very visual, so they need to look at the chart for a second and then they remember the patient. The key is building those features into an EMR.” Such modifications can provide physicians with a comfort level that they can't get from learning to click and do data entry, Ms. Mullaney says.

To enable his doctor to focus on his patient, Mr. Patton's practice has the computer screen in each exam room mounted on an adjustable arm. “He can pull it over and look at the screen and the patient side by side,” he says. “We didn't turn our backs on the patients with the charts.” Others welcome the use of the iPad as an input device for EMR, since it is less obtrusive than a computer and allows the doctor to maintain more eye contact with the patient.

For doctors who are struggling with EMRs, Ms. Mullaney recommends designating “super users.” She notes that when a practice begins EMR implementation, there are usually a few people who pick it up more quickly. These relative EMR prodigies can be the support people for those who are struggling. Not only does the personal attention from another user help make sure that all questions are answered, but super users also relieve the person in charge of EMR implementation from having to be everywhere.

Using these strategies means EMR is less of a headache for the practice owner—even one preparing for his grand exit. OM

On the Other Hand …
Although most experts encourage EMR adoption, some claim there's a case to be made for those physicians nearing retirement to skip it. “If they are looking to retire five years from now, perhaps it's worthwhile to invest in EMR, but if they will retire in a year or two, it would be a waste of money from the selling standpoint of the practice,” Mr. Mirabent says.
Mr. Borglum concurs. For one thing, he notes that the federal incentive offered may be insufficient to recoup the cost of converting to EMR in their remaining time at the practice, even if one does qualify for the full $44,000 available to those who implement by the end of this year. Another thing to consider, according to Mr. Borglum, is the potential lack of interoperability between systems. Sharing of data between systems will be accomplished using HL7 interfaces and other standards which are vendor independent.
Mr. Borglum says that HL7v2 is a hospital-based program, not a physician program. “All the major physician platforms support HL7v3,” Mr. Borglum says, “they just haven't all achieved it—causing continued lack of interoperability.” Be sure to check your vendor's system-to-system compatibility and inter-operability.
Lack of interoperability would cause a problem for specialists who get referrals from hospitals, Mr. Borglum says. The government has granted hospitals an exclusion to buy EMR systems for their doctors; however, they usually buy them only for the primary care physicians. Different EMR systems won't have total interoperability, Mr. Borglum believes. Should the specialist not purchase the same EMR as the PCP, he says the specialist places himself outside the referral loop unless the PCP takes the extra step of finding a referral pad. Ophthalmologists typically don't receive many referrals from hospitals, so the concern may not translate into real-world hardship for most practices.
For those who do, Mr. Borglum suggests maybe waiting until interoperability is universal. Compulink's Mary Ann Fitzhugh disagrees. The meaningful use criteria established by the ONC require an EMR system demonstrate that it can exchange key clinical data electronically with healthcare information exchanges and other vendors. Just make sure your vendor is certified and guarantees to maintain that certification as ONC requires continued proof of interoperability.
Mr. Borglum also rejects the position that not having an EMR will have a negative impact on the value of a practice. Should a retiring ophthalmologist selling his practice have adopted the platform of the community and integrated it, that practice has the asset value of that platform, Mr. Borglum says, but has not added more goodwill value. “If the seller hasn't adopted anything yet, he merely has to do a paper-to-digital conversion, as does anybody else who is established in practice. If he has adopted the wrong EMR, then there is the extra cost of dumping all those records to paper and converting to the platform of the community.”
Should a practice feel compelled to go EMR to avoid the eventual noncompliance penalty, he suggests purchasing a system on an application service provider model. “It's a cloud computing solution,” Mr. Borglum explains, rather than an in-house installation. “The servers, the management and the updates are all hosted remotely, and you can access your software and operate it from any computer in the world.” He says that the cost is about the same as for office-based EMR software. “It's typically about $500-$600 a month, whether you want to purchase and amortize the cost over five years, or whether you want to lease.” And though additional computer hardware may be required, the practice will avoid the costs of an IT manager. It's a safer, less expensive approach, Mr. Borglum feels, particularly well-suited for physicians who aren't going to be with the practice long-term.