PracticeMaker(R)- Ophthalmology Medical Records

® EMR
Electronic Medical Records

This is an open memo to all Ophthalmologists who are interested in electronic medical records. DON'T DO IT if you are only thinking you will make money on the deal...you will NOT! Think of the following costs in going electronic...

Greatly increased infrastructure costs..more computers, increased electric costs; local storage of ALL papers you collect for at least 7 years (any record scanned MUST be saved, too...you cannot throw this away...paperless my butt!); off-site database storage; off-site scanned document storage
Initially decreased productivity (may last for 4-6 months...if not longer)
Training costs for new staff, especially older staff members how may not be computer savvy!
Need for full time scribe in EACH exam room to enter information (do NOT think that templates make things that easy..I know..you still have to enter real finding and remember to erase the standard "WNL" entry!)
Need for full time technical support (unless you are a techie like me, you will basically need a full-time person on the premises to fix monitors, printers, scanners, electronic interfaces, network wiring, network switches, battery backups...geez my hands are hurting from typing so much!)
Decreased reimbursements in future years will make recouping this investment much harder!
CMS is considering decreasing our reimbursements by 24-27%! So if they take away in 4-5 years 1% of 25% less..how much will you really lose by not doing EMR
Any stored data you have can be used against you to decrease your reimbursements even more. Think about this...you are a glaucoma specialist who sees only "train wrecks" and off course your visual outcomes are awful. Medicare and any other insurer will decrease your income because your patients do worse that other Ophthalmologists!
There are NO guarantees that the next administration will not halt future payments
Do you really want to have to check weight, blood pressure, calculate BMI and record vaccination records on all your patient!
Physicians I believe are being railroaded into adopting EMR.

One of the EHR-EMR blogs I read noted that at most a busy practice may loss $5000 in Medicare reimbursments per year if they do not have EMR (this implies the practice collects $500,000 in Medicare payments), but at the same time this practice would not have to incur the high cost of maintaining the infrastructure of the "paperless EMR" as noted above.

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That being said, for the past 4 years I have been trying to come up with a design for electronic medical records that would be simple, straightforward and easy to use, while at the same time being flexible to most general Ophthalmology practices. I designed PracticeMaker® in 1993 and for the past 15 years have increased its feature set to make the managing of our medical practices easier while not costing "an arm and a leg". This task has been achieved. Now, it is time to put these same ideas and ideals into an EMR just for us...Ophthalmologists!

Below are some screen shots from the current alpha version of PracticeMaker®EMR.

This screen is where the Review of Systems is captured. The list on the right side fills with all the possible selections for that part of the ROS. On this screen shot, the user clicked the "Allergy-Immunology" button (a red dot lights up) and the the list fills with the choices for that section of the ROS. To append a symptom to the selected list, the user simply clicks on one of the listed selections (can't get any easier than that). Every time a new medical encounter is started, all the data in these fields fills into a corresponding field in the encounter records thus fulfilling the recording of the ROS for all encounters.

Note: The buttons on most screens are large to make using TOUCH-SCREEN monitors easier. I have found a combination of touch screen and mousing very efficient (and the patients think it is cool and high tech, too).

ROS screen

The screen below shows all current medications for the patient. This can be viewed when NOT in an encounter, or while the encounter is being recorded. You have the ability to enter ALL prescriptions a patient takes, and flag them as...

prescribed by another physician ("O" is checked)
Dispensed as Brand only (the "B" is checked)
a currently used medication (the "C" is checked)
an OTC product (the "T" is checked).

When you print a prescription for the patient, up to five prescriptions will print onto a half sheet of paper and each Rx has its own independent log. Eventually, e-prescribing will be attached to this system.

Medication list

This is the Overview screen for a patient's examination. Many EMRs have a similar design. On the left is each component of the exam. The buttons across the top direct you to the major sections of the exam (Overview, Assessment, Plan, etc) while the buttons along the side navigate you to the page where that part of the examination is recorded. On the top right side is a list of all testing done so far for THIS encounter. The bottom right shows the IOP measurements for THIS encounter, along with the last record pachymetry results which are used re-calculate the IOP (IOPc) using the CCT results (the calculations are built into the software).

Exam overview

One of the newest screens is the Refractive Records Page below. You are allowed unlimited refraction related records for each encounter. On this screen, the patient has a Lensometry, Keratometry, Autorefractor and Refraction record. Related fields are "stacked" for maximum quickness of comparison (you can easily compare your Autorefractor with your Refraction However, you can have a pre and post-cycloplegic refractive record, or even several eyeglass records. This is a real world screen.

$Refractive screen$

Below is the screen for entering the examination of the Lens. Each page has the exact same layout for consistency. You can add a finding to each eye individually, by making selections on the left side that fill the examination fields on the top right, or build OD and then apply it to OS because both sides have the same findings. You can also use previous findings from any previous examination date where that encounter is locked (and cannot be altered).

Lens exam

This screen is the IOP trend page. It has been exaggerated to show extra properties of this screen, which include the bar graphs, images of optic nerves and which medications the patient was taking when the associated IOPs were recorded. On the bar graph is the measured IOP and the CCT corrected IOP in parentheses. This screen in invaluable!

IOP trends

The final screen for your approval is the retina drawing screen. As you know, most Ophthalmologists are not Rembrandt, and we cannot be expected to draw pictures. It is way to time consuming. With this is in mind, I have designed a simple "Kidz-Pix" style of graphics page. First, you select the type of graphic you want, here "Horseshoe Tear", and get a list of images to select from depending on the location of the tear. Once selected, you click on the grid box that approximates the location of the lesion. You can then create a narrative from scratch or return to the Retina screen and select what you want to be the narrative from the pre-entered list of selections.

Retina exam

If you like what you see so far, stick around and more images will be posted, soon. Please feel free to call and schedule a web demo of the alpha version so you can see what else is on my plate awaiting your approval. Remember, we are in this together for the long haul!

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