business of ophthalmology
Digital records coming to ophthalmology

A new federal incentive program and emerging ophthalmology-specific digital record systems are expected to fuel to use of such technology

Richard G. Davis, M.D., implemented his own health IT system nine years ago and has proposed an ophthalmology-specific EMR to GE
Source: Richard G. Davis, M.D.


A scribe (right) enters clinical data into the office EMR of Richard S. Hoffman, M.D., (center) as he discusses care with the patient
Source: Richard S. Hoffman, M.D.

The reluctance of ophthalmology practices to embrace digital record-keeping technology may soon fade in the face of an expansive federal incentive program and an increasing number of commercial options that meet national specifications for their needs.
Ophthalmic practices looking to adopt, administrative software, electronic medical records (EMR) and e-prescribing have new incentives under the American Recovery and Reinvestment Act of 2009 (ARRA, PL 111-5). The federal measure, which was signed into law in February, included financial incentives to adopt EMR systems as well as new federal privacy protections.
The new federal funding law includes measures to create national guidelines that aim to ensure both emerging and existing health information technology geared specifically toward ophthalmology practices will be sustainable and interoperable.
Both initiatives aim to build on the long-touted advantages of health information technology (HIT) to improve patient safety through reduced record-keeping errors while saving money and time for practices that use it.
There are specific benefits HIT systems can bring to ophthalmology offices, according to Richard G. Davis, M.D., Huntington, N.Y., who has used a digital record system he modified for his practice for the past nine years. Advantages he has found over paper record systems include potential savings in staff time and paper storage and the ability to access records and clinical images from multiple locations, including mobile devices.
“So there’re no sticky notes getting lost or important information ending up on paper that can get misplaced,” Dr. Davis said.
Those potential advantages have long been countered by technological challenges stemming from potentially steep learning curves, the incompatibility of new technology and potentially large costs. These obstacles have discouraged HIT adoption and led less than 10% of ophthalmology practices to add such systems.

Federal action underway

The federal health IT law aims to address both cost concerns and questions about whether expensive HIT systems will meet minimum performance and compatibility standards.
The law provides $19 billion for HIT grants from the Department of Health and Human Services (HHS) and for Medicare and Medicaid incentives to encourage physicians, hospitals, and health care providers to use health information technology to electronically store and exchange patients’ health care data.
The law funded incentive payments of up to $18,000 per physician for the first payment year (2011), with incentive payments in subsequent years of up to $12,000, $8,000, $4,000, and $2000, and ending in 2015.
Physicians who already report using a “certified” EHR that is also capable of e-prescribing will no longer be eligible for earlier e-prescribing bonuses through Medicare but will be eligible for the new HIT incentives. Physicians who do not implement HIT systems until 2013 will have their first payment limited to $15,000. By 2014 the maximum payment for new adopters will drop to $12,000.
Physicians in federally designated rural and urban health professional shortage areas will have their incentive payments increased by 10%.
The roughly 60% of ophthalmologists who accept Medicare payments must adopt HIT systems by 2015 or face a 1% reduction in Medicare payments that will increase to a 3% reduction in 2017 and beyond. Federal health officials can increase penalties up to a 5% reduction in Medicare payments after 2018.
The measure allows federal officials to make penalty exceptions on a case-by-case basis for “significant hardships,” such as rural areas without sufficient Internet access.
The federal law is considered part of President Barack Obama’s overall health reform effort and creates a federal leadership role in developing HIT standards by 2010.
The specifics of the new HIT standards are among numerous aspects of the law that will need to be fleshed out by federal regulators. The measure requires HHS officials to establish interoperability standards, implementation specifications, and certification criteria by Dec. 31, 2009.
Among the key features of the law that regulations will need to define are the specific requirements for a physician to be considered a “meaningful EHR user.” The law describes such physicians as those who use “certified” EHR technology; who use that technology to improve quality and coordination of health care; and clinicians who submit required clinical quality data to the government.
Federal regulations will create a certification process and definitions for new and existing systems. “There are no systems that are ophthalmology-specific that are certified at this point,” said Nancey McCann, director of government relations, ASCRS, about the lack of finalized federal HIT standards.
Ophthalmology advocates, including ASCRS/ASOA and the American Academy of Ophthalmology, are working with the Certification Commission for Healthcare Information Technology to develop certification criteria for ophthalmology-specific EMR systems. The finished criteria are not expected to be released until 2011, according to Ms. McCann.
Other unknowns include what clinical quality information will be required and what degree of interoperability with other EMR systems will be needed. The tight timeline for federal regulators to develop certification, interoperability and quality standards may change, Ms. McCann said, because industry and government groups have been unable to agree on such standards in over a decade of discussions. An extension of the December deadline has been sought by ASCRS.

Keys to HIT success

Federal technology standards are the first of numerous challenges and obstacles to ophthalmology practices successfully integrating heath IT systems into their practices.
Although it is critical for these practices to ensure that the systems they are considering purchasing are certified under the as-yet-unfinalized federal certification process, no specific EMR systems are endorsed by ASCRS.
Ms. McCann urged ophthalmology practices to ensure that the system they purchase is certified, meets eventual federal interoperability standards and includes mandatory features, such as e-prescribing. “If you have an EMR system you can get the federal bonus if you are a meaningful user,” she said.
Another stumbling block for ophthalmology practices can be the lack of a physician within the office who is a strong advocate of the EMR and who helps to push the practice through its HIT “adoption pains.”
“Every failure I’ve experienced was because the physicians were not using the technology adequately or properly,” said Steve Robinson, O.C.S., C.O.E., ophthalmic practice consultant, Advantage Administration, Dallas.
Like many ophthalmologists contacted for this article, Elizabeth A. Davis, M.D., director, Minnesota Eye Laser and Surgery Center at Minnesota Eye Consultants, Bloomington, and adjunct clinical assistant professor, University of Minnesota, Minneapolis, said stories of costly adoption failures at other practices has led her office to wait for better options before proceeding with an EMR.
“We have heard of many of the disasters out there with these systems,” she said. “We’d rather wait until all of the bugs are worked out.”
The concept of a physician champion has worked well at Drs. Fine, Hoffman & Packer, Eugene, Ore., where Mark Packer, M.D., clinical associate professor of ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Ore., has served that role since the three-practice group added a digital practice management system and an EMR component in February 2007. The practice’s administrator, Laurie Brown, also spearheaded the adoption and implementation of the Centricity IT system (General Electric, Fairfield, Conn.).
“We have been extraordinarily successful thanks to the creativity, energy and enthusiasm of our ‘expert users,’ including certified ophthalmic technicians and front office employees,” Dr. Packer said.
While the specifics of the technology are important, Mr. Robinson said practices also need to carefully examine how much time it will take for their physicians to become comfortable with the digital record-keeping system. The implementation phase can be difficult because it will likely impact their style of practice.
Richard S. Hoffman, M.D., clinical associate professor of ophthalmology, Casey Eye Institute, Oregon Health & Science University, also at Drs. Fine, Hoffman & Packer credited his practice’s approach to implementation for a relatively trouble-free process. The practice systematically transitioned to digital records over six months, starting with the practice management package for the front office. Only after that component was running smoothly did they institute the EMR.
Their EMR use began with new patients, while established patients remained on paper charts. Once the physicians became comfortable with the EMR, established patients were transitioned to electronic records by scanning their charts into the EMR system. “Eventually, by six months we were completely electronic with very little trauma,” Dr. Hoffman said.
Ophthalmology offices that have added HIT systems also encourage others considering adopting the technology to consider whether one vendor can supply all of the components they require, including the clinical system, administrative features and e-prescribing components.
Many physicians also place a premium on systems with simpler interfaces. Some systems capable of more tasks can overwhelm clinicians who are not technologically inclined.
John Pinto, president, J. Pinto and Associates, San Diego, urged clinicians looking to adopt a digital record system to first perform or purchase a cost-benefit analysis for their practice to help determine the kind of HIT system they would financially benefit from the most.
Mr. Pinto also suggests visiting other practices of similar size and type that have had an operational EMR system for at least a year to identify challenges they faced and the solutions they devised. “When my clients run afoul of EMRs it’s usually because they have not done site visits of similar practices,” Mr. Pinto said.

Health IT use expected to grow

Although less than 10% of U.S. ophthalmology practices are thought to have HIT systems that include EMRs and e-prescribing, Ms. McCann said many ophthalmologists with such systems in place have inquired about how the law applies to them. Physicians in such offices may be eligible for reimbursement starting in 2011 if their HIT systems become federally certified and the physicians are individually “meaningful EHR users.”
The extent of HIT costs that ophthalmic practices will be able to recover through the federal reimbursement program could be significant since each physician in a multiple-physician practice could qualify for the full $44,000 in grants. However, federal grants and Medicare bonus payments may not cover all HIT costs related to installation and ongoing maintenance, which can be expensive.
Health information technology ranges from an off-the-shelf EMR software system expected from Wal-Mart at a cost for $25,000 for the first physician in a practice and $10,000 for each additional clinician to comprehensive health IT systems that cost more than $100,000 per physician.
Larger practices with information technology professionals on staff and technologically savvy physicians will likely continue to lead a broader adoption of EMRs in ophthalmology, Mr. Pinto said.
Dr. Hoffman said that for his practice the transition to electronic records required a full-time IT employee to address “server issues and computer glitches.”
“We have several satellite offices in addition to the various entities within our building utilizing the virtual world and our IT person is invaluable,” Dr. Hoffman said. “It is an added expense but well worth it.”
Dr. Hoffman said smaller practices may benefit from hiring an employee who can function as a part-time IT professional in addition to their other duties within the practice.
Such lessons may prove valuable to ophthalmology practices where significant expansions in EMR use are expected. Less than 10% of Mr. Pinto’s clients now use an EMR but he estimates that up to 20% more are likely to adopt such a system within the next two years.
“EMRs are on the verge of much deeper and faster market penetration,” Pinto said. “We are just now moving from the early adopters to the middle majority stage.”

Editors’ note: Dr. Davis is developing HIT software for Allscripts (Chicago, Ill.). Ms. McCann is director of government relations for ASCRS. Mr. Robinson is an ophthalmic practice consultant with Advantage Administration (Dallas). Dr. Davis has no financial interests related to her comments. Dr. Packer has financial interests with General Electric (Fairfield, Conn.). Dr. Hoffman has no financial interests related to his comments. Mr. Pinto is president of J. Pinto and Associates (San Diego).

Contact information

E. Davis: eadavis@mneye.com
R. Davis: eyeguy@precision-eyecare.com
Hoffman: rshoffman@finemd.com
McCann: nmccann@ascrs.org
Packer: mpacker@finemd.com
Pinto: pintoinc@aol.com
Robinson: steve@srr2.com