by Guy M. Kezirian, MD, MBA, FACS
Over the years I have developed some experience with software systems and the evolution of information technologies. My company, SurgiVision® Consultants, Inc. has released more than a dozen software programs since 1998 for diverse applications. We have been involved with the design of software products for devices, studies, technology monitoring, communications, clinical outcomes, field sales support, QA, and nomogram development. Security concerns, development cycles, evolving standards, infrastructure changes, new devices and platforms, convenience, design, and of course costs all create tremendous pressures that keep life interesting for us, and requires us to stay current.
Our commitment with both our software engineers and our customers is to stay up to date with technology. This caused us to migrate from Windows based architecture to Web based platforms very early (in 2003) and we are now moving to the cloud using virtualized servers. These changes always incur initial costs that are offset by savings over time, and are absolutely necessary to maintain a leadership position in the industry. The investment is also worthwhile because we see the benefits our software brings to patients and to the surgeons who use it in their daily practice.
It is from this perspective that I would like to share some observations that may be helpful as you consider EMR systems for your practice. I frame my comments around three questions:
- What are you buying?
- Who are you buying it from?
- How will your choice affect your future?
What are you buying?
EMR (sometimes also referred to as Electronic “Health” Records or EHR) is sometimes misused as a catch-all term to describe software that performs many disparate functions, many of which are fall outside the scope of “medical records.” ASC scheduling, payroll, accounting, billing, patient scheduling and recall, and other services are not strictly considered EMR functions. With the ACA mandates, the former scope of clinical-record-only EMR systems has expanded to include patient portals, electronic prescriptions, reporting of certain “meaningful-use” outcomes, etc. 
Using a working definition of EMR to include patient demographics, past medical history, clinical records, scheduling, patient portals, correspondence generation, lab and clinical testing integration, patient educational resources (links, articles, etc.) and e-prescribing, it is clear EMR applications are complex and evolving structures. Add to that compliance with evolving ACA requirements and the challenges with technology evolution mentioned above, and one obvious truth emerges: Your EMR system must be able to evolve with changing needs.
In software, evolution means “upgrades” that can include both software and hardware components. Cloud based systems minimize costs for both software and hardware upgrades, and therefore it is my strong recommendation that EMR systems should be cloud based. Let Amazon, Google, Microsoft and the other big cloud providers deal with hardware issues, and focus your attention and resources on running your practice. Let the vendor manage software on their servers and systems, not yours. Software upgrades are now done using “managed code” or software that is housed and run from web-based servers so that upgrades are instantly distributed to all users. Managed code provides tremendous efficiencies in new version deployment and overcomes many of the operating system issues encountered with locally installed applications.
In essence, what you should be buying with an EMR system is information management. But with most systems, the answer to “what are you buying” includes computers and other hardware, service contracts, upgrade fees and a lot of cost that exists only to support what you really want, which is information management. Most current EMR vendors are heavily invested in their Windows-based, locally installed architecture and they want you to buy it whether it meets your needs or not. What you want to buy is a service, not hardware, and functionality, not infrastructure.
Cloud based systems can evolve, they can run on multiple platforms (including mobile devices) and best of all someone else takes care of the hardware headaches. Just rent what you need on the cloud. This avoids the heavy capital expenditures and maintenance costs, and makes upgrades all but invisible.
NOTE: Cloud providers are battling fiercely and end-user costs are plummeting. It is better to negotiate short-term commitments for your cloud services, and shop them frequently. Some vendors have dropped priced by more than 60% in 2014 alone. If you are paying 2013 fees, it may be time to renegotiate.
The legacy EMR providers will either convert their systems to run in the cloud or they will die. If you are still using a local-area-network based software, the sooner you move to the cloud, the better.
Who are you buying it from?
The EMR industry has a bad reputation that is completely justified. Many physicians and practices have been burned by EMR companies. Some of us remember “Ivy”, which was offered by Alcon until they abandoned it in the late 1990’s, costing physicians a great deal of money and inconvenience. Many other companies have come and gone as well. Since the ACA and prior EMR mandates were passed the number of EMR vendors has ballooned, all looking to cash in on the cash incentives provided by the legislation. Most of these vendors will not survive and many have failed already. The need for EMR vendors to stay current requires enterprise level infrastructure, intense capital requirements and ongoing re-investment. That is hard to do in a startup, so many companies have failed.
Several people have commented on the ease-of-use of EMR systems that are designed specifically for ophthalmology. This is an important point. Systems that serve general medicine will be less responsive to ophthalmic needs. While they may have larger development teams, those teams will be focused elsewhere. Our techno-driven diagnostics require software interfaces and there are hundreds of devices in use.
Be sure to pick a vendor who knows ophthalmology and supports ophthalmic devices already, and not one who promises to develop the interfaces at some point in the future.
How will your choice affect your future?
One of the good effects of the ACA are the requirements to develop standards for storing clinical data. Unfortunately, those standards have not yet reached refractive surgery. Nevertheless, the issue of migrating patient data to a new EMR vendor will become simpler in the future. It may never be a simple flip of the switch, but it will not be cost-prohibitive, either.
To use a metaphor, few home buyers take samples of the foundation to insure it is sound. The assumption is that if the house is standing and was built to the housing code then the foundation must be fine. The EMR infrastructure equivalent to a house foundation is the “data model” or the structure of the database that is used to store the patient records.
Unfortunately, with EMR systems, there is no equivalent to the “housing code” for designing data models and most EMR vendors just store data in haphazard files. Doing so allows them to save costs and focus resources on the front-end user interface, but it has several negative consequences for the user:
- Poorly designed data models become slow as storage amounts increase;
- They are not amenable to migration to other systems if you change vendors, as some people have experienced in the past. Disorganized data storage effectively makes you a captive to your EMR vendor;
- They make reporting difficult; and
- They will be handicapped when compliance to data standards becomes a requirement.
Data modeling is dry and technical and the only way to know if the system you are considering has a well-designed data model is to consult an expert. Alternatively, we could create a reference for the SurgiVision® DataLink Forum users to share information about systems.
Even more alternatively, we could create a cooperative to build our own high quality data model in the cloud, and require EMR vendors to use it. That way if you decide to switch EMR vendors, you wouldn’t have to move the data at all. This is something I’ve thought about for several years, but the industry wasn’t ready for it. It may be time to revisit the discussion.
Ophthalmologists are a bright bunch and many of us enjoy working with software. But designing and maintain EMR systems is serious business and the consequences for making mistakes are severe. Unless you are willing to give it your all, I encourage you to resist the temptation to develop a system yourself or become involved with a company that requires you to design templates or help with software design.
For our part, SurgiVision® will never offer an EMR system—the field is too crowded and it doesn’t build on our core competencies in analytics, ophthalmic technologies and clinical studies.
Those who resisted converting to EMR may have made a wise choice given the rapid migration of technology to the cloud and the costs of converting platforms. But I believe that the tipping point has been reached and it is time to make the move. Stories about EMR systems slowing down the practice flow are describing legacy platforms that are not well designed. Newer systems add efficiencies and are becoming essential, particularly in a field like refractive surgery where state-of-the-art technology is part or the brand.
Sooner or later EMR will be universal. If you are in the position to select an EMR system for your practice I encourage you to consider these recommendations as you evaluate your options:
- The EMR system should be cloud based;
- The system should already be fully enabled to support ophthalmology and refractive surgery; and
- Data should be stored in a solid, transferrable data model that anticipates accepted standards such as HL-7  and DICOM. 
With these criteria in mind, there are only a few systems to choose from. Maybe physicians should pick the best and all become shareholders so they can have the resources they need to stay current. If physicians own the company, we won’t be abandoned.
http://www.hitechanswers.net/ehr-adoption-2/meaningful-use/ http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage1vsStage2CompTablesforEP.pdf http://www.hl7.org/ http://medical.nema.org/