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April 2007

Practice Perfect: Information Technology
Use a Systems-Based Approach to Get the Most Out of Your EMR
By J. C. Noreika, MD, MBA

In some quarters, the electronic medical record is seen both as an antidote to the erosion of quality in medical care and the bankrupting price of an enormous social entitlement, namely the provision of state- or employer-sponsored health care. Insurance companies, employers and governments are espousing the rapid adoption of EMRs.

Meanwhile, physicians and other providers view this push for EMRs warily. Many suspect that it is just another unfunded mandate and that no good can come of it. The largest demographic cohort of practices - the solo practitioner and the small group - has avoided EMRs, citing cost, change and chance. But suppose EMRs could improve the quality of care for the patient and reduce overhead expenses for the physician?

Now a Mature Technology

Issues such as nomenclature and standards for image data capture have been, or soon will be, resolved.1 And although the EMR industry continues to evolve, with the consolidation of many small companies into fewer large ones and the outright failure of others, changes in the fundamental concept of the EMR will represent improvements at the margin, not wholesale innovation.

Since the EMR is, at its core, a tool, it is useful to draw a comparison with other tools of the profession. For instance, the phacoemulsifier, along with the IOL, is now indispensable in the treatment of cataracts, as is the automated visual field analyzer in the management of glaucoma - but it was not always that way. Not surprisingly, many of the objections to EMRs are echoes of those heard years ago regarding the adoption of phacoemulsifiers, IOLs and automated visual field analyzers. It is human nature to resist change, especially change that threatens the existing order. But, as the Luddites found, change - especially technologic change that addresses some fundamental need  - is inevitable.

What Is EMR's Core Benefit?

Physicians and consultants talk a lot about office efficiency, which is often a euphemism for "let me see more patients in a shorter period of time so that I can do something else." This can become a zero-sum game that usually runs contrary to the benefit of the patient. If EMRs enable physicians to redirect their efforts away from the chimera of office efficiency and toward practice effectiveness, the proverbial pie could be expanded and value created for all parties.

EMR as labor-saving tool - what labor will be saved? To be embraced as beneficial, a tool must not only make a task more efficient and effective, but also must lower cost. In the case of automated technology, cost savings are generated primarily by the replacement of labor. This is fortuitous for the ophthalmology practice because its highest fixed cost is its staff. This is not to suggest that a small ophthalmology practice with a support staff of 10 people will magically be able to reduce that number to six. For while the EMR can be used to replace some labor, such as the doctor's scribe or the assistant billing clerk, its main value lies in its capability to enhance the effectiveness of highly compensated personnel such as the physician and technician.

How does the EMR enhance practice effectiveness? It boils down to the stuff of advertising slogans: "Have all the data that you need where you need it, when you need it, and in a format that you can use." Therein lies the core benefit of the EMR. All other gains, including overhead expense savings on chart storage, risk reduction in terms of medical liability, and the cost and inconvenience of lost records, are derived from this.

A Systems-Based Approach to IT

Ophthalmologists are systems-oriented. It is their systematic approach as much as it is their native intelligence and abilities that makes them successful practitioners and excellent technicians.

Using the prior example of phacoemulsification, it was the rigorous, systematic approach to the extraction and replacement of the natural lens that transformed this once difficult and risky procedure into a "minor" procedure that is fast, safe and easy.

Why can't the EMR succeed on its own merits? Like the phacoemulsification machine, the EMR should not be viewed as a stand-alone technology. To be successful, it must be seen as one tool within a system of technology.

In this system of clinic operations, the EMR is the key component of a triad of technology that includes the practice management system (PMS) and the data management system (DMS). Ancillary software applications such as an optical dispensary module, a Web site, and voice over Internet telephony (VOIP) can enhance the value of these three core components.

If a practice adopts an EMR without realizing its potential within the context of a system of information technology, it has bought an expensive and resource-consuming documentation device that may, ironically, add cost and unproductive time to the patient encounter. I believe that this is why some practices have seen their initial foray into the EMR fail.

Seamless Interchange of Data

The EMR and PMS must exchange data accurately and instantaneously. All but the oldest and most proprietary PMS can be connected to a new EMR by writing digital code that "bridges" the two tools. If a practice's PMS cannot be linked to an EMR, it behooves the practice to first update its obsolete PMS.

You should not have to input data more than once. That is the primary goal of this linkage between the PMS and EMR. Demographic and insurance information should flow seamlessly from the PMS to the EMR. Coding and billing information, once captured in the EMR, should move accurately to the PMS. The practice should be able to customize which data is in each of those tools.

Exam images should be readily available. Ideally, a technological system will permit the capture, interpretation, organization and recall of images with minimal labor. These images range from the mundane - such as insurance cards, lab tests and correspondence -  to the sophisticated - including corneal topographic and wavefront data, and digital images of the optic nerve and macula.

EMR fully integrated into practice. I contend that EMR's greatest value to practice effectiveness can be garnered by connecting equipment that the technical staff normally operates - such as the autorefractor, autolensometer, autokeratometer and autophoropter - to the DMS and thus have their output immediately available to the EMR. The most expensive time in a fully capacitated medical practice is that expended when highly compensated employees, such as the ophthalmic technicians, optometrists and ophthalmologists, are in front of the patient. Time spent writing and at the keyboard is nonproductive and detracts from the patient's interaction with the provider. In my practice, all the aforementioned technology connects to my EMR and its DMS (both from ChartLogic). This not only saves time but reduces technical error. The EMR also interfaces with the optical shop software so that prescriptions for glasses can be completed by the optician and sent, via the Internet, to the optical lab for rapid turnaround. The EMR and optical shop software both link to the PMS for billing purposes.

Coding assistance. Fear of incorrectly coding and billing an encounter leads many physicians to undercode. This can represent a significant area of revenue leakage. It is my opinion that the physician should be solely responsible for proper coding and billing. To assist those doctors who remain compliance-challenged, some EMR offerings contain software enhancements that help to rationalize the coding and billing function and educate the provider.

The Inevitability of the EMR

All but a few ophthalmologists, such as those who are contemplating retirement or who are practicing in areas with very little competition, will need to confront the EMR. There is simply too much social, political and economic pressure to do otherwise. But the purchasing decision of an EMR must not be approached in a vacuum. As this article attempts to convey, the EMR is not a stand-alone product. It represents the key component of a systematic process and as such requires careful consideration of the totality of medical practice operations.

There is inherent economic risk, but the incorporation of a system of health information technology can transcend this risk and, if done correctly, offers both improvement of the patient's quality of care and the enhancement of the practice's bottom line.

I know that my fellow ophthalmologists will adapt. After all, they accepted and later embraced phacoemulsification, the IOL and the automated visual field analyzer. History has shown many times over that those who oppose innovation that benefits the buyer soon cede their ability to compete. More specifically, I have seen that the EMR and the benefits it brings can make us better physicians and improve our satisfaction with our profession. As end-users, these are benefits that can't be ignored.


1 See the Nov/Dec 2006 Practice Perfect at


Dr. Noreika is a founding partner of Excellence in Eye Care, a practice in Ohio. He has long had a keen interest in technology and practice management, and is a popular speaker at the Technology Theater at the Academy's Annual Meeting.