At the London Vision Clinic, we decided to transition to an electronic health record (EHR) system in 2008 basically because dealing with the quantity of paper files was becoming unmanageable. If we added up the time each staff member spent handling the records—locating patient files for that day and putting away patient files from the day before—we essentially had at least one full-time staff member dedicated solely to managing patient records. Additionally, one staff member was responsible for manually entering the data from every patient chart into our Excel database for outcomes analysis.
Additionally, we observed a shortcoming of physical records, in that a paper file can be in only one place at a time. If a file is in use by one staff member, no one else can access it until he or she is finished, which is problematic from an efficiency standpoint. Then there is the issue of a misplaced file, forcing all staff to search high and low for the chart, which could be anywhere in the clinic—in a staff member’s in-tray or erroneously filed under a patient’s first name. In addition to being stressful, this scenario is a complete waste of time.
A substantial amount of physical space is required to store paper files, and there are environmental implications of printing all of these materials. Altogether, these factors contributed to our decision to implement an EHR system.
THE IMPLEMENTATION PROCESS
The process of implementing EHRs was long and consisted of several steps. First, we had to turn our existing paper records into electronic records—but still keep the paper records so that they could be reviewed during the transition. We hired a professional scanning company to scan all of our charts, and we ended up with a PDF of each patient’s file. Despite outsourcing this task, we had to manage the process closely, as it was necessary for us to keep track of which patients were scheduled for visits, so that we did not send off their records at the time of their appointment. That was the main difficulty in an otherwise relatively painless process. For patients seen in the interim between when their charts were first scanned and when the EHR system was fully implemented, their records had to be rescanned on a daily basis to keep the PDF records up to date.
Generally speaking, the next step in the implementation process depends on which EHR system is adopted. Some off-the-shelf systems come equipped with predetermined fields that are built into the EHR and cannot be changed. In that case, the transition can be relatively quick, as the user just learns how to use the software.
In contrast, some vendors give practices a blank canvas and the tools with which to build a custom EHR system. The system we selected, manufactured by Nextech, is completely customizable, so we were able to decide which data we wanted to capture, how we wanted to capture it, and how it would be displayed. The process of designing an EHR template can be long, as the user not only needs to learn how to use the system but also has to create the template. The vendor will often assign an EHR specialist to assist with this process. We knew exactly what we wanted, as we had spent a lot of time designing our paper forms and were thus specific about our templates, which took about 6 or 7 months to create.
The beauty of our software is that we can continue to update it ourselves over time, without having to contact the vendor. We make changes to our template on a weekly basis, if not daily. As new technologies and treatments continue to be introduced to the practice, it is important to have the flexibility to update one’s EHR system to correlate.
STAFF TRAINING AND MOTIVATION
Although training and motivating the staff to use EHRs was difficult, it was easier than we expected. Because we spent so long preparing our template, we could train the staff in advance of the actual transition. Most staff members participated in training sessions, and clinicians were able to use the templates for a few sample patients prior to the day we switched. Everyone was aware of how his or her part of the EHR system would work well in advance of the switchover date, and this eased the transition process. It also enabled us to iron out problems with our template design and fix them before we had gone fully into EHR use. Then, just before the switchover date, we held a weekend of full staff training so that, by Monday, everyone was fully prepared for the EHR system to be up and running.
One of the major advantages of using EHRs is the ability to see all patient data in one place. Each record carries forward information from past visits and can be built upon as new information is available. So, for example, the user can readily view a refractive surgery patient’s preoperative refraction, target refraction, and achieved postoperative refraction at each follow-up visit. A picture of the patient’s entire case can be clearly displayed and his or her progression tracked without having to flip through paper files.
Other advantages of EHR include the amount of time and money that can be saved by eliminating the need for staff to cart paper charts around. Additionally, clinicians can access their patients’ data from all over the world by logging into the system remotely and pulling up their charts. This allows them to respond to medical emergencies with much greater knowledge. In regard to outcomes analysis, moving to EHR meant that every data point recorded would be available for analysis without further work, expanding the data available for analysis and saving time.
The ability to store a larger quantity of documents, images, and videos is also a plus. Whereas with a paper chart system the clinician might print one view from a topography exam, with the EHR system five different views can be saved as image files and included in the patient’s file. The clinician can then select several images and compare them side by side, rather than flipping back and forth between images.
Another advantage of going paperless is that the EHR system can be linked to one’s practice management system. Our EHR is linked to patient appointments as well as patient records and demographic information; it is also linked to staff to-do lists so that, in each patient’s record, various tasks for different staff members can be created related to that specific case, further increasing practice efficiency.
PEARLS FOR NEW USERS
New EHR users must take time up front to ensure that they understand how the system will work with their practice’s existing processes. A substantial amount of training and practice with dummy patients will be required before going live so that the staff understands how routine practice is going to work once the EHR system is implemented.
When selecting a vendor, it is important to consider your budget and what you want to get out of the system. For us, a main motivator for choosing Nextech was the ability to customize the templates. Further, as a research center, we were keen on gathering as much data as possible and choosing what we wanted to record. However, choosing a customizable system meant we needed to dedicate time and effort to making it the best EHR system for our practice. If you do not want to put in the time, I suggest selecting a system that is less customizable and more preprogrammed.
A last pearl is to make the EHR system look, feel, and sound as similar as possible to the paper system that was previously in place. With a customizable template, you can use your own language and have the layout appear as the staff members are used to seeing it on the paper record, so that they already have a general idea of how the system works prior to its implementation.
Although the process of implementing an EHR system requires a great deal of forethought and motivation, many benefits are afforded by the use of these systems. Savings in cost and time, greater access to patient data, and more space to store and organize materials are all benefits of the use of EHRs. Additionally, based on our experience, there are also hidden capabilities of EHR use, such as the ability to automatically create staff to-do lists, that can further increase a practice’s efficiency. In our experience, implementing an EHR system has been a worthwhile investment. n
Timothy J. Archer, MA(Oxon), DipCompSci(Cantab)
• Research Manager and Programmer, London Vision Clinic, United Kingdom
• Financial disclosure: None