Ophthalmology Clinic Sees EHR Productivity Gains

Ken Terry

July 28, 2015

A 13-provider eye clinic in Asheville, North Carolina, reaped an internal return on investment of 41% from an electronic health record (EHR) over the course of a 5-year period, according to an article published online July 22 in Ophthalmology. That figure includes discounting for inflation and the cost of capital from 2007 to 2011.

Asheville Eye Associates paid off its initial investment in hardware and software, amounting to $500,250, in less than 3 years, the study said. The chief contributors to positive cash flow were savings on administrative staff, higher optical revenues, and the increased productivity of some physicians in the fifth year.

The administrative cost savings resulted from changes in workflow that led to increased efficiency during the study period. The number of transcription and medical records staffers dropped immediately, and starting in year 4, the practice was able to reduce the number of billing and reception staff as well. By 2011, these layoffs resulted in annual savings of nearly $600,000 a year.

The ability of the physicians to send prescriptions electronically to the optical department also produced incremental optical revenues ranging from $216,000 to $385,000 a year. In an interview with Medscape Medical News, lead author Robert E. Wiggins Jr, MD, MHA, explained that when the ophthalmologists gave patients paper prescriptions, they would often walk out the door and go elsewhere for their glasses. Electronic prescribing induced people to visit the optical department, where they would often see something they liked. The patients can still get a paper prescription at checkout if they prefer to go somewhere else, he added.

The productivity of the physicians dipped a bit in the year the EHR was introduced, because seven of the providers cut back their schedules during the first month after implementation of the system. After that, the average productivity of the clinic remained constant for 3 years. But in the fifth year, three full-time-equivalent providers upped their productivity by slightly expanding their schedules, resulting in 1.23 more patients being seen daily across the clinic. The providers' ability to see additional patients increased overall clinical revenues by more than $800,000 that year.

"Our clinic was a busy, high-volume practice to start with," Dr Wiggins told Medscape Medical News. "Those providers were able to see a few more patients a day. Those small changes in productivity really amounted to a substantial increase in profitability."

Dr Wiggins attributed much of this productivity gain to repeat visits by patients whose data were already in the system. Instead of having to create a new electronic record for each patient, which takes time, the physicians were able to update the records they already had. "That's where the efficiencies of EHR really start to kick in," he said.

Also in 2011, the group bought a new practice management system that was interfaced with the EHR. As a result, the physicians were able to enter charges directly into the system at the point of care. That raised the percentage of captured charges, improved billing efficiency, and increased collections.

The practice received relatively little in the way of government EHR incentive payments, because the meaningful use program was just getting underway during the study period.

Before the clinic switched from paper to electronic records, it already employed scribes who doubled as technicians. Since the EHR arrived, Dr Wiggins noted, "Scribes have become essential in maintaining productivity with EHRs. We were using them before, but they've become even more critical in terms of documenting and e-prescribing and keeping the physician from facing the computer for the entire exam."

In addition, the practice changed the scribes' workflow so that they began making follow-up appointments. The scribes no longer had to walk the patients to checkout, and the receptionists had less work to do.

Although the clinic did not hire more scribes, it did add an information technology technician. Other incremental EHR-related expenses included EHR maintenance costs, scanning of paper medical records, and increased printing costs in the initial phase of implementation.

For most of the first year, Dr Wiggins admitted, the physicians were working longer hours and patients were waiting longer to see physicians than they had been. But he himself was able to finish his reports to referring physicians at the end of each exam, which made an enormous difference in his work schedule.

"I don't save anything until the end of the day now," he said. "My process used to be that I took a stack of paper charts, and I'd spend an hour or two at home every night going back through them and dictating the reports to the referring doctors."

Dr Wiggins has a mostly consultative practice, which is not true of some of his colleagues. Nevertheless, his study does not break down the differences in the post-EHR productivity of different subspecialties, noted Rishi Singh, MD, medical director, clinical systems office, at the Cole Eye Institute, a unit of the Cleveland Clinic in Ohio. Dr Singh, who coauthored a study showing that implementation of an EHR did not raise his group's productivity or its revenues, said those subspecialty differences can be important in measuring the effect of an EHR.

Dr Singh also criticized the current study for not showing pre- and postimplementation P values. Without them, he said, there is no way of knowing whether the productivity improvements were significant or not.

Dr Wiggins responded that in studies involving cash flow projections, P values are not relevant. However, he maintained, the productivity improvements were significant.

Dr Singh also pointed out that during the 5-year study period, changes in reimbursement could have affected the outcome in ways that were unrelated to the EHR. For example, the practice might have started billing for the use of a new piece of technology.

Dr Wiggins said he could not think of anything like that during the study period. In any case, he noted, cutbacks in Medicare reimbursement during those 5 years would have more than counterbalanced any such changes.

Dr Wiggins received site visit fees from Allscripts. Dr Singh has disclosed no relevant financial relationships.

Ophthalmology. Published online July 22, 2015. Abstract

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