Steven Rosenfeld, MD, FACS (Chair, EMA Ophthalmology, Modernizing Medicine)
Paul Gallogly, MD, (Lead Consultant, EMA Ophthalmology, Modernizing Medicine)
When deciding to make a major purchase, we approach the seller with a list of items that we must have. For instance, when we make the decision to purchase a home, we have a mental or physical list of things that we want, such as “a master on the main.” Likewise, there is a complimentary list of things that the home should not have, such as noisy neighbors.
Given that you spend as much time in your office as you do in your home, perhaps more, the same care needs to be taken when selecting an electronic medical record. Helpfully, in September 2011, Chiang, et. al. published an excellent article on the features an ophthalmology-specific EMR should have.1 As vendors scramble to implement these suggestions, it is also vital that ophthalmologists consider the things that their EMRs should not do, for a poorly designed EMR will wreak more havoc on your day than an annoying neighbor ever will. In effect, your EMR will be living with you, so make sure it does not have the following attributes that will cause you to grow to disdain it.
1. Should not make you design it
Many EMRs on the market today ask that physicians design their own templates. This is not only time consuming, indeed would require many days of not seeing patients just to enter the data, but can force an ophthalmologist to try to fit a very complicated patient into a pre-set template that does not address his or her issues properly. Thus, the physician is left editing the template at nearly every visit, another time-consuming task. The solution is to do away altogether with the idea of templating medical notes. The EMR that we are currently working with comes out-of-the-box with the knowledge of a 2,000-page ophthalmology textbook. It easily harnesses that information to present you with only the options that you need for any given diagnosis and then remembers your preferred settings. Each time you use the EMR, it automatically updates the way you dose your medications and do your procedures. There is no need for you to make any additional effort to tell the program what you do each time. Once it is done once, the system learns, but allows you to choose unique items for what are doubtlessly your unique patients.
2. Should not make it difficult to render drawings
An EMR that uses a mouse to render drawings on cornea and fundus diagrams is not only time consuming, but sometimes impossible. We are not graphic artists, we are ophthalmologists, but our diagrams are just as important. An EMR for ophthalmologists needs to allow us to quickly translate what we are seeing on our exam onto the screen and touch-based technology is a perfect vehicle for this. A few swipes of your finger should signify where the retinal tear or cataract is, how big it is, and any other features you choose to note.
3. Should not take away from the doctor-patient encounter
As Dr. Pauline Chen confessed last year in the New York Times, after implementing an EMR, “In order to use the computer, I had to turn my back to the patient as I spoke to him. I tried to compensate by sitting on a rolling stool but soon found myself spending more time spinning and wheeling back and forth between patient and computer than I did sitting still and listening. And when my patient did talk, his story came only in spurts because every time I turned my back to him to type, the room fell silent.”2 This is, of course, unacceptable, but all too common. We have found that it is absolutely imperative that the EMR not take away from our encounter with our patient. The EMR with which we are working allows the physician to rest an iPad on his or her lap and easily touch a button here or there to record an exam and history, all while maintaining eye contact with the patient.
4. Should not ask you to make further capital equipment purchases
The capital equipment costs for an ophthalmology practice are high and we should not be asked to purchase an expensive server to utilize an EMR. The advent of so-called cloud computing has made the need for an office-based server a thing of the past and quite an unnecessary purchase. Cloud based systems are far and away better suited to managing patient records. They are available anytime, anywhere, on any device. If an EMR company is providing the remote servers, they can support massive economies of scale in redundancies and backup, providing the service without interruption in almost every scenario. If the server in your office has a hard-drive fail, or the power supply dies, or someone spills coffee on it, everything must stop until it is fixed. Having an EMR that utilizes cloud computing allows you to at least have one less piece of equipment that you are responsible for.
5. Should not cost you time
As physicians, time is our most valuable resource. More minutes or even hours spent with your EMR, mean less time for your patients or your family. Your EMR simply cannot cost you any time and ideally should be a time-saver. According to a New England Journal of Medicine article, as of 2008, only 4% of physician practices in the United States were using fully functional EMRs.3 The reason for this often comes back to the amount of additional time many EMRs ask physicians to devote to documentation-- time we just don’t have. The motto of the company we are working with is “What’s Your Time Worth?” Time considerations need to drive everything an EMR company does.
For years, many EMR companies have been concerned with the needs of pharmacists and administrators, neglecting the needs of physicians and expecting them to adapt their practice to the EMR. But physicians have been voting with their feet and rejecting the vast majority of the products on the market. Recently, the tide has turned and ophthalmologists are demanding the things we need our electronic records to do. Let us not forget the things that they also must not do.
- Chiang, M, et al. Special requirements for electronic health record systems in ophthalmology. Ophthalmology 2011. 118(8):1681-7.
- Chen, P. “An Unforeseen Complication of Electronic Medical Records.” The New York Times, April 22, 2010.
- DesRoches, C. Electronic health records in ambulatory care—A national survey of physicians. N Engl J Med 2008; 359:50-60.