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Young Ophthalmologists
EHR: Where Are You On the Continuum of Adoption?

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Momentum has been building toward the adoption of electronic health record (EHR) technology. The Academy conducted a survey in 2006, which indicated that about half of the membership had or were planning the implementation of an EHR system within two years. EHR adoption was more common in larger group practices, but was also on the rise in small practices. It was greatest in multi-subspecialty groups, with 71 percent planning EHR implementation in the next two years. The latest Academy/AAOE member survey indicated that 31 percent had converted to an EHR system and 25 percent planned to convert within two years.

undefined The average price for EHR purchase and implementation was $49,712 per physician, with an average maintenance cost of $1,066 per month per physician. Most of those who had implemented EHR (12 percent of the sample) were satisfied (71 percent), with 33 percent reporting that physician productivity increased and 29 percent reporting decreased practice costs. The most valued outcomes of EHR implementation included guaranteed access to patient information from all offices; detailed, clear documentation; no lost charts; and retrospective analysis of clinical treatments.

Federal Initiatives and Financial Incentives
The movement of the industry is toward electronic records that are capable of using nationally recognized interoperability standards, which is a key defining component of an EHR. There are systems that may be thought of as an “EHR,” but really don’t have the functions of an EHR. With the passage of time, electronic records that are incapable of exchanging information interoperably will lose their relevance. The Office of the National Coordinator for Health Information Technology initiated an effort to define terminology through the National Alliance for Health Information Technology. Thus, the term electronic medical record (EMR) is on course for eventual retirement.


One centerpiece of the national health information technology strategy is a “national network of networks”: connecting state and regional health information exchanges. The Nationwide Health Information Network (NHIN) is intended to provide a secure, nationwide, interoperable health information infrastructure that will connect providers, consumers and others involved in health care. The NHIN will enable health information to follow the consumer, be available for clinical decision-making and support appropriate use of health care information beyond direct patient care so as to improve health.

Another federal initiative has been the certification of electronic health records, led by Certification Commission for Health Care Information Technology (CCHIT). CCHIT has developed EHR system-certification programs for general ambulatory care, but nothing specific for ophthalmology. These certification criteria are broad and cover basic functions of EHR systems, but are not really useful for ophthalmic practices. Eye care is on the road map for specialty certification in 2011.

The stimulus bill provides for incentive payments for adopting health information technology. In 2011 and 2012, physicians can receive $18,000 for their first year of implementing EHRs and demonstrating meaningful use, and up to $44,000 over five years.
  • After 2012, physicians will receive $15,000 their first year and up to $41,000 over five years.
  • For physicians serving in designated health professional shortage areas, payments will be increased by 10 percent.
  • For physicians not adopting EHRs, negative incentives begin with a 1 percent penalty in 2015 for those who failed to report in 2014 and increase to 2 percent in 2016; penalties are capped at 3 percent in 2017 and beyond. 

Definitions of “meaningful use” or criteria for receiving these stimulus payments will be finalized by the end of this year. 

Continuum of EHR Adoption
EHR adoption is not as simple as switching on a button and everything works perfectly. Often, a system is implemented in stages, with focus given to one aspect of the system at a time. In the Academy member survey described above, some of the worst outcomes of EHR implementation included increased non-productive time inputting data, lack of drawing capability, lack of incorporation of visual fields and fundus photos, and lengthy implementation. Thus, even when an EHR system has been purchased and implemented, the most advanced features may be delayed or never activated.

In the hospital world, there is a continuum of EMR adoption, known as the EMR Adoption Model™. Health Care Information and Management Systems Society Analytics has developed this as a tool for hospitals to chart their progress in creating a paperless patient record environment, with Stage 7 being the most advanced. Hospitals can also see their progress in relationship to their peers. In the first quarter of 2008, across the country, 4.4 percent of hospitals were at stage 4 and above, 28.4 percent were at Stage 3, 35.3 percent were at Stage 2 and 32 percent were at Stage 1 or 0.

The Academy has adapted the EMR Adoption Model to create the Ophthalmology EHR Adoption Model. There are eight stages of adoption, beginning with Stage 0 — limited clinical automation (such as a practice management system) and digital fundus image acquisition — all the way to Stage 7, a fully operational system that can exchange records with all entities within a regional health network. Stage 7 has not yet been fully realized, but is clearly the goal of the federal government, as well as the Academy.

Many practices are at Stage 2 or 3. In Stage 2, a document management system scans patient charts, rendering them electronically accessible. Images and data reports may also be scanned into this system for ready access. However, the clinical notes and documentation are still written on paper, not entered by keyboard.

In Stage 3, notes and interpretation are entered electronically. Templates may be used for entry of some data. Images can be accessed via an intranet or a local area network.

In Stages 4, 5 and 6, practices use such features as electronic order entry, automated patient reconciliation (to eliminate errors) and full image and data access through a secure network. At each stage, there are implications for IT staffing and resources and for compliance with recognized standards.

Interoperability = IHE Eye Care
The Academy survey found that a critical barrier to the adoption of EHR systems was the ability to integrate with existing ophthalmic imaging equipment. Currently, ophthalmic practices have to either factor compatibility into purchase decisions (e.g., stay with the same vendor) or purchase customized interfaces from the EHR system vendor or another third party. The ability to connect diagnostic devices (e.g., fundus camera, automated perimeter, ophthalmic tomography device, ultrasound, etc.) to the EHR system creates interoperability. This is similar to USB “plug and play” where, because of the USB standards agreed upon by different vendors, you can buy any USB device and assume that it should work.

Since 2005, the Academy has sponsored a standards-based approach to interoperability known as IHE (Integrating the Healthcare Enterprise) Eye Care. This is a broad effort to reach all vendors in eye care, involve users in the identification of needs and then write a broadly agreed-upon specification to meet those needs. IHE strives to make your information systems and your devices all work together. The goal is to ensure that the ophthalmologist or practice administrator can select diagnostic devices based on their clinical value and other advantages, without worrying about compatible interfaces.

In the IHE workflow, patient demographic information is sent electronically from the EHR system to the diagnostic equipment, ensuring that the right data is connected to the right patient, and eliminating manual entry. Once registered, patients can be scheduled for routine diagnostic tests. When completed, procedure information is automatically sent from the diagnostic equipment to the billing system in this efficient electronic workflow.

IHE standards can facilitate the digital exchange of information across networks, enabling practices to access patient data anytime and anywhere. IHE standards can help bring peace of mind to practices struggling with the risk involved in office automation — it helps to ensure that all the devices will work together in the end and data will not be lost from IHE-compliant devices if the vendor goes out of business.

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About the author: Flora Lum, MD, is the policy director for quality of care and knowledge base development for the Academy.