October 2019


What ophthalmologists should be doing today
Making the most of an EHR

by Liz Hillman EyeWorld Senior Staff Writer

Percentage of office-based physicians with electronic health record system, 2004–2017
Source: Percentage of office-based physicians using any electronic health record (EHR)/electronic medical record (EMR)
system and physicians that have a certified EHR/EMR system, by U.S. state: National Electronic Health Records Survey, 2017


With electronic health records (EHRs) being used by 85.9% of office-based physicians1 and being incentivized through federal regulations, it’s clear the paperless record system is here to stay. As such, there are ways to maximize its potential and minimize its impact on practice flow.
Physicians are not required to use a certified EHR, though choosing not to runs the risk of not meeting requirements in the Merit-based Incentive Payment System (MIPS) program. MIPS payment adjustments, William Koch, COA, pointed out, only apply to Medicare fee-for-service patients, but the MIPS program requires reaching a threshold (60%) of reporting quality data on all patients. In addition, small practices of 15 or fewer Medicare-eligible clinicians have the option of submitting a hardship request that would exempt them from the EHR-focused Promoting Interoperability category of MIPS and potentially limit the penalties for small practices without EHR.
“Some physicians make a conscious decision not to implement an EHR because they think the cost of the system outweighs the potential penalties,” Mr. Koch said. “However, the potential penalties are rising, which may cause a change in this philosophy. Not implementing an EHR may be advantageous to a physician who is retiring in the next couple years before the penalties increase beyond the point of diminishing returns.”
Candy Simerson, FASOA, also said that at some point, it will be difficult to remain profitable on a paper system. In addition, as the market moves to value-based payments, practices will need to produce data that validate patient outcomes. Metric tracking and report generation will also be difficult with paper files, she said.
“Many practices still on paper have senior physicians who want to hold out for retirement. However, if they want to sell their practice in the future, these physicians will take a hit to the valuation due to the fact that the practice is still on paper,” Ms. Simerson said. “The longer one waits, the more difficult it is to catch up.”

Choosing what to document

When Richard Davis, MD, started his practice 20 years ago, his record system was digital out of the gate. At this time, going with an EHR was “much more difficult than today,” he said. Overall, Dr. Davis thinks EHRs bolster efficiency, save space, help with regulatory compliance, automate pattern tracking (such as assessing trends charted out over time), and allow the physician to see the entire record easily in one place.
“I think electronic documentation has the potential to be a better solution but also has the potential to create vast records that are meaningless,” Dr. Davis cautioned. “Using the ‘all normal’ button to start a patient chart and modifying it to illustrate the patient’s condition is a usual tactic, but it may create misinformation.
“On the other hand, if you have a great first examination outlined, pulling that forward and modifying it as appropriate saves a lot of time on subsequent exams. All too often, though, I see vast examinations documented for trivial problems, and it makes me wonder what was actually done,” Dr. Davis said.
Mr. Koch said paper records may have resulted in too little documentation but EHRs, as Dr. Davis expressed, tend toward “too much documentation due to automated functions, such as copy forward and auto-populating.”
In terms of what needs to be documented for insurance reimbursement, Mr. Koch said this is a complicated question.
“It differs based on multiple factors. The exam, for example, should be coded based on the documentation after the exam rather than documenting to reach a certain level of service,” he said. 
Ms. Simerson said documentation for insurance reimbursement includes the patient complaint, testing, diagnosis, assessment, and plan.
“Be sure to use your Medicare LCD (local carrier determinations), as well as specific payer websites, for required documentation. Certain CPT codes require a specific diagnosis or diagnoses, in addition to those in the assessment and plan, in order to be reimbursed by payers,” she said.

How to document

The sources EyeWorld interviewed for this article were split on the utility of scribes for enhancing EHR management.
Dr. Davis said he sees 70–80 patients daily and records interactions without the help of a scribe.
“My intimate relationship with the computer and the patient enhances my interactions with both,” he said. “I have all the needed information at my fingertips and sit so I swivel easily between the computer and the patient. I can show testing results to patients, find information that I need to make decisions, send out scripts, make eyeglass prescriptions available, send out reports, do the billing, and close the chart all while interacting with the patient. Occasionally, I will ask the circulating tech to complete some tasks, such as renewing multiple meds or sending a report to a physician not in the database, but 99% of the charts are finished by me alone.”
From a cost-saving standpoint, Dr. Davis said that scribes should be used judiciously, not as a panacea. He also thinks younger ophthalmologists, especially new hires, should learn a scribe-less system.
On the flip side, Carrie Jacobs, COE, said using a scribe can maximize efficiency and allow the physician to focus solely on the patient.
“They can focus on the patient without having to stop the exam to document as they go, boosting productivity,” Ms. Jacobs said. “This translates into shorter time for the patient in the exam room, which makes the appointment more efficient and leads to the ability to book more appointments, which means increased revenue.”  
One tip Ms. Jacobs offered is to have scribes pull up the patient’s EHR before the doctor enters the room so there is no time wasted logging in and loading electronic documents for the exam to begin. She also said that pairing one scribe with one doctor seems to be the most efficient as the pair can establish a rhythm together.
“In our practice, our technicians are also scribes. They conduct all portions of the visit that a tech normally would do including the patient history. Then when the physician comes into the room, the tech puts on their scribe hat,” Ms. Jacobs said.
She also noted that scribes should never make diagnoses or treatment suggestions beyond what the physician directs. It’s the physician’s job to review documentation that was scribed in, add any pertinent information, order and review testing, and sign off on the record. 
Mr. Koch said his practice uses scribes because many high-volume doctors prefer not to type during exams. He added, however, that he knows a lot of doctors who successfully see a standard volume of patients while performing their own data entry.
In addition to potentially increasing physician efficiency, Ms. Simerson said use of scribes—with proper training and protocols—can reduce physician burnout. Scribes should be trained to anticipate what the physician will say and what needs to be in the record for proper reimbursement, she explained, noting that they also can add value by asking the physician questions if something in the visit gets missed.
“Generally, scribes tend to be people who are seeking higher education and perhaps taking a break to learn more. The average turnover rate is about 25% so plan for ongoing recruitment and have a formalized training program so they can quickly learn and add the most value,” Ms. Simerson said.

Enhancing EHR use

Dr. Davis said he uses iMedicWare, which was designed with input from ophthalmologists. For efficiency, he said systems should minimize the number of screens opened and clicks per encounter, have automation for regularly repeated tasks with little lag time, and a small learning curve. The capability to add a dictation file, unless you’re a fast typist, is very useful, Dr. Davis said.
Mr. Koch said the practice where he works uses a paperless technology solution for patients to check in, which automatically populates EHR with demographic data, insurance data, and consents.
Ms. Simerson noted that most EHR systems allow the user to create “my phrases” and other shortcuts that can make for efficient documentation. Overall, Ms. Simerson said she thinks EHRs can enhance documentation when used appropriately with proper training protocols and ongoing monitoring to ensure compliance with guidelines.
In terms of enhancing cost effectiveness of EHRs, Mr. Koch said “it is what it is.”
“Mandated EHR utilization is more about gathering and exchanging data to improve healthcare outcomes and control costs,” he said.
Ms. Simerson said that an independent, neutral consultant can help advise and assist with selection and contract negotiation when purchasing a new EHR system. The practice should buy only what they need and not sign up for an indefinite commitment, she said.

At a glance

• While EHRs are not required, it could be difficult to achieve MIPS positive payment adjustments without them.
• Auto-populating EHRs can lead to overdocumentation. Be conscious of what you choose to automate with these systems.
• Use of scribes is a personal choice. Some doctors find they increase efficiency, while others wonder if efficiencies are offset by the cost.

About the sources

Richard Davis, MD
Ophthalmic Consultants of Long Island
Huntington, New York

Carrie Jacobs, COE
Chu Vision Institute
Bloomington, Minnesota

William Koch, COA
Administrative director
Texas Retina Associates

Candy Simerson, FASOA
iCandy Consulting
Tucson, Arizona


1. Myrick KL, et al. Table. Percentage of office-based physicians using any electronic health record (EHR)/electronic medical record (EMR) system and physicians that have a certified EHR/EMR system, by U.S. state: National Electronic Health Records Survey, 2017. National Center for Health Statistics. January 2019.

Relevant financial interests

Davis: None
Jacobs: None
Koch: None
Simerson: iCandy Consulting

Contact information

Davis: rdavis@ocli.net
Jacobs: Carrie.Jacobs@chuvision.com
Koch: wkoch@texasretina.com
Simerson: candysimerson@gmail.com

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