EHR System Shows Little Effect on Ophthalmology Practice

Pam Harrison

April 22, 2015

Implementation of an electronic health record (EHR) system in a large multispecialty ophthalmic practice made little difference to revenue or productivity compared with in the pre-EHR era, the first study of its kind suggests.

Despite the lack of clear financial benefit, the authors still consider the EHR system to be beneficial, noting it makes communication easier between colleagues and with patients. They published the results of their study online April 16 in JAMA Ophthalmology.

"I think you are seeing a lot of skepticism right now in the US because after 5 years of this program, people expect things to be fixed and ready to go," Michael Boland, MD, PhD, from the Wilmer Eye Institute and Health Sciences Informatics, Johns Hopkins University, Baltimore, Maryland, told Medscape Medical News. "But I think it's going to take a longer-term investment before we start seeing some of the advantages of EHR, like sharing data between practices. Although I think they will manifest themselves eventually, it's just unlikely we're ever going to get magical interoperability and immediate quality improvement." Dr Boland writes in an accompanying editorial.

Rishi Singh, MD, from the Cole Eye Institute, Cleveland Clinic, Ohio, and colleagues performed a retrospective case-control study comparing pre- and post-EHR periods at the Cole Eye Institute for differences in net revenue, patient volume, revenue-to-volume ratio, diagnostic and procedure volume, capital and implementation costs, EHR incentive payments received, and coding volumes.

They identified a total of 28,161 patient encounters: 13,969 in the pre-EHR period and 14,191 in the post-EHR period.

After implementation of EHR, there was a mean net revenue decline of $44,732 per month, although the difference between pre- and post-EHR was not significant.

Specific services such as oncology and plastic surgery did post significant gains after EHR implication, at $17,627 (P = .02) and $9954 (P = .009) per month, respectively. However, comprehensive neuroophthalmology and pediatric ophthalmology all showed significant declines in net venue per month.

Dr Singh observed that it was interesting to see these differences in ophthalmic subspecialties, as detected in this review, and notes that they might indicate how the EHR system efficiencies differ even between specialities of ophthalmology.

Overall, the total volume increased by a mean of 217.0 visits per month from 2011 to 2013, the authors add.

Again, however, differences in total volume between pre- and post-EHR implementation were not significant, with some exceptions depending on the service.

Overall, there was also a decrease in the revenue-to-volume ratio, again with some exceptions depending on the service.

As the authors point out, analysis of revenue-to-volume ratio can determine whether practitioners were receiving greater revenue per visit from improved electronic charge capture or new coding features within the system.

The volume of diagnostic tests and procedures billed was similarly unchanged after conversion to EHR, although there was an overall increase in code volume.

The actual amount spent in capital costs, which included an image management system, legacy medical device upgrades, and license fees for the EHR, was $424,880 in 2011 and $1,146,984 in 2012, for a total cost of $1,571,864.

This figure does not take into the total personnel and ongoing costs of the EHR system in the same 2 years, which approached the total amount spent in capital costs.

"We showed that overall, the economic change between pre- and post-EHR was statistically equal, although there was significant investment," Dr Singh told Medscape Medical News.

"We had hoped that the EHR system would make us more profitable, but this wasn't shown."

Dr Singh did acknowledge, however, that the EHR has allowed the group to reconcile chargers faster. "We reduced our billing time — charge out — from 35 days to under 14 days," he noted.

The group also acknowledges that there are a number of "soft metrics" that have improved thanks to implementation of the EHR, including an ability to review charts from home or consult with a physician without setting up another appointment, as charts and images can be shared; reduced duplicate imaging, as images are kept in a single image repository; and better communication.

"We still meet once a week for 2 hours to review ongoing changes, and we also have to maintain a staff to implement changes," Dr Singh said. "But I would recommend EHR to others because I am able to answer patient phone calls, send out refills for medications, and review tests — and incidentally, right now, I'm flying on a plane while I do this for you."

Act Increases EHR Use

In his editorial, Dr Boland points out that the Health Information Technology for Economic and Clinical Health Act adopted in 2009 was designed to increase the use of EHRs by US healthcare professionals and hospitals via a system of incentive payments.

"As intended, [this act] has had a clear effect on the adoption of EHRs, with the most recent estimates showing almost 80% of US physicians using one."

This corresponds to evidence provided by a 2011 survey done by the American Academy of Ophthalmology in which the expectation is that approximately 80% of ophthalmology practices have an EHR by now, a rate that closely corresponds to rates found for medicine overall in 2013.

"I think the bottom line on the success of EHR in medicine overall is that it really depends on the practice," Dr Boland said.

"We have reports from people who are really unsuccessful with it, while for others, EHR seems like a wash: Physicians are seeing roughly the same number of patients at the added expense of the EHR," he said.

"So I think an EHR system requires a lot of careful planning and thought on the part of the practice on how they want to use the EHR, because if you don't plan for it, you're going to get something you don't like."

The Cleveland Clinic receives licensing and consulting fees from organizations outside of the clinic for EHR implantation projects. The authors and editorialist have disclosed no relevant financial relationships.

JAMA Ophthalmol. Published online April 16, 2015. Article abstract, Editorial extract

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