Paperless Practice
Taking Your Office Paperless
A nuts-and-bolts explanation of how to replace your paper files with organized electronic files.
BY SHELDON H. KREDA, O.D., F.A.A.O., Lauderhill, Fla.

Anything you can do I can do better." We've all heard this phrase at least once in our lives. And if computers could talk, we'd hear it a lot more because it aptly applies to their superior performance over ours at traditional paperwork.

Yet many O.D.s resist converting to a paperless office, not realizing that their fear of leaving the security of paper only keeps them from a more efficient and enjoyable practice. Here, I'll explain how to unlock the full potential of computers.

Priorities

To successfully go paperless, you need several computers that are connected to each other by a network. Any computer attached to the network can share information and resources (such as printers). The Windows operating system makes networking a snap to set up and maintain.

Gauging your needs

Track typical patient flow through your office to determine where you need computers. Most offices are divisible into three specific areas:

1. clerical
2. clinical
3. optical.

Let's take a trip through these areas in my office as an example.

Clerical. The hub of my office is the reception desk -- it's where all office visits start and end. Two staff members work here, and each has her own phone and computer. While one may be on the phone scheduling an appointment for a patient using the electronic appointment book, the other collects patient fees and prints a receipt. The multi-tasking capabilities of the Windows operating system enable each staff member to perform several jobs simultaneously.

New patient check-ins are a snap when using software programs that allow patients to enter their personal and medical information directly into the computer via a touch screen. These programs serve as useful marketing tools that provide great detail about patient symptoms and visual needs. You can place a computer that's set up for direct patient use in the waiting area or on the front desk. A staff member enters demographic and insurance information at the time an appointment is made, which speeds up new patient check-ins. Many eyecare plans allow us to obtain insurance authorization via the Internet. This is also accessed at the front desk computer.

Our receptionist uses the computer to calculate and record payments. She can print out forms for insurance claims at the front desk or later at the business office computer. When she schedules a patient's next appointment, the date automatically prints out on the receipt. The business office computer provides an environment free of patient intrusion. This is the place to do accounts payables, insurance billing and tracking, financial reports, collections and receivables.

Now let's look at the need for computers in the clinical areas of a practice.

Clinical. Each exam room and electron-ic instrument should be part of the network. In our special testing room, we have a network computer that contains retinal imaging, topography and visual fields. These instruments connect to the computer in this room, which in turn allows us to access the findings on any computer connected to the network.

On the exam room computer, a new electronic medical record automatically records the patient's name, age, exam date and time. From here, I can bring up the patient's prior exams, retinal images, topographies or visual fields. I also use it to play PowerPoint demonstrations to explain my findings and recommendations to patients.

Another benefit of a paperless practice is that after you record spectacle, contact lens and pharmaceutical prescriptions, you can then print them out or view them in chronological order to help with clinical decision making. Use an electronic routing form to convey information such as professional services, fees, diagnostic codes, future appointments, spectacle and contact lens prescriptions to the front desk receptionist and to the optician.

Optical. At the optical computer, the optician can bring up the routing form with the doctor's instructions and recommendations along with the prescription. The computer records frame and lens specifications and generates lab orders when the patient completes his selections. Print these lab orders or access them through an in-house lab computer. Add optical fees to the patient's electronic fee slip so you can take payments either here in the optical or at the front desk.

A computer in the lab provides more functions and eliminates a lot of printing. Submit orders electronically and track them more efficiently and maintain a frame and lens inventory or track purchasing patterns. Lower lab expenses by keeping a database of supplier costs.

Don't forget your own office

A computer here allows you to review electronic medical records, design contact lenses and generate a contact lens order form (this is great for tracking delays or lost orders). You can also generate referral letters, check your schedule and view financial reports in the comfort of your own office.

Smaller offices

If your office is small and you have a few staff members, then start out small and add as you go along. One of the first things you can do is merge the functions of the optical and lab computers. Similarly, the reception computer can perform the added functions of the business office. A computer in your private office is a luxury that you can do without if you have a small practice.

Electronic is nicer

Use a paper form if it isn't part of a patient's permanent record or serves only a temporary purpose. For example, you usually throw away routing slips after each visit, so you can continue to use paper. If a computer can do the job better -- why fight progress? Processing paper forms is a habit you can break by replacing each task one by one over time. Move your practice into the 21st century by fully utilizing the benefits of your computer. Your office will run more smoothly and you'll help save a few trees to boot.

Dr. Kreda is in private practice in Lauderhill, Fla. He's an author and frequent lecturer on practice management and clinical practice issues.

Electronic Medical Records in My Optometric Practice
By John Warren, O.D., Racine, Wisc.

Many healthcare providers have embraced computer technology for diagnostic and even therapeutic uses, but they've yet to see the need or benefit of having electronic medical records (EMRs) versus traditional paper patient records. An EMR system has several advantages over paper records:

• no legibility issues with an EMR
• more efficient use of staff and provider time, once doctors and staff members learn how to use the EMR system
• providers can take the entire office with them, or connect to the office system when needed after hours (I take my patient database home every day or two)
• multiple office staff members can work with a patient chart at any one time
• you can't misplace an electronic chart behind the tint tank in the optical lab
• coding and billing can be handled by the software, eliminating lost revenue from under-coding, leaving out a procedure on a multi-procedure visit and helping ensure that over-coding is not a problem during an audit
• improved patient flow with an interactive history module.

Taking my office paperless

In January 2000, I decided that it was time for me to "go paperless." I'd been using one of the leading optometric practice management software programs for a little more than 2 years, but couldn't add an electronic medical record (EMR) with the current software, as there wasn't an EMR module available for it.

I was faced with a choice and an opportunity. I could either change software systems entirely, or I could add a new EMR application to the software I was currently using. I chose the latter and set out to define the system I wanted to use.

I wanted to avoid systems that use "exam templates," as I don't have a template for each patient encounter. What I wanted was a "data depository" for all of my exam data. I've used proper coding and billing procedures since I opened my practice in 1997. I figured that if I was putting in all these data, the program should assist me with choosing the appropriate CPT code(s) to report the visit.

I didn't find a program that would do everything I desired, so I called my old friend Jim and his wife Kelley. They're database programmers, and had done a medical record program for a cardiac transplant unit for one of their area hospitals. We modified their cardiology program for an optometric/ophthalmic medical record and have produced our own EMR application.

Once we got serious about producing an EMR for my office, the first thing I had to do was make sure that each of the six computers on my office network was up to the task of running the software we were creating. This is a significant factor, as most of the EMR programs available have considerable hardware and network requirements. Fortunately, with the falling prices of hardware, this doesn't have to be something that busts the budget.

Some quick tips

Most of the systems I've looked at require what's now an entry-level workstation for each user and a fairly high-end computer to act as the server for data storage. A solid backup plan and the hardware to safely store your data are also vital. I recommend using a CD burner for this. You should talk to the vendor for any system you're looking at to discuss their recommendations, and backup your data at least once a day, possibly twice per day if you have a multi-doctor practice and see a large number of patients every half day.

It's important to have a stable network design. There are several good books available about networking Windows, but if you don't have an interest in setting up your own network, find someone local to set it up and get your infra-structure ready for the system you decide to go with. One advantage of setting up your own network is that when a problem develops, the network engineer is in the office!

Must-have EMR features

• A system that allows a trained user to enter patient encounter data quickly and accurately.
• A program that allows the patient or doctor or staff member to record a complete history. Because the level of history is often the limiting factor when applying the proper CPT code to a visit, be sure that the history portion of the program is robust. In my opinion, a program that defaults any exam or history findings as "normal" unless otherwise changed is unethical.
• A complete exam record. It's critical that the program accurately reflect the patient encounter. If it's not recorded it didn't happen, and it shouldn't be recorded if it didn't happen. The user should be required to enter findings for each test or observation performed.
• Assistance with coding and billing. As O.D.s become more involved in medical eye care, it becomes more important to either understand coding and billing well, or have a tool to help you. The exam record should reflect the patient encounter, not drive which procedures or observations are performed during the encounter.
• A program that will grow with your practice. While hard drive space is easy to come by, some programs have limits to the size of the database. Be sure that the program you are looking at is scalable for possible future developments. Some databases have a limit of one gigabyte.

As computer hardware has improved and dropped in price, the abilities of EMR applications have expanded rapidly. The next time you're at a trade show, take a few minutes to see if an EMR is right for you and your practice.

You'll have to make a few changes to the patient flow in your office and to your exam routine, but you'll be more efficient in the end. You'll be amazed by the time and cost-saving abilities of the currently available EMR products.