Schertzer Glaucoma and HealthIT

Someone asked me what EMR to use; it depends on what would be best for you

2010-07-28T12:00:53Z

A friend asked me what EMR to get and here’s my response (edited a bit from its original form to make it into more of an article than a chatty email message.)
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Personal preferences; learn from the mistakes of others:

So much of using an EMR depends on personal preference so it is best to try different ones, even seeing if you can get different vendors to let you use them in your own office setting for a few weeks to know if it is right for you. Some people may rave about the EMR they use and it may turn out that particular one is not good for you. That being said, you also do need to try ones that people recommend, or at least ask any potential vendors for a list of their clients in your area so you can visit them to see it in action and get their opinions. Some offices may only be using one module of an EMR and had too much trouble with the rest of the EMR so gave up on it!

EMR I’m currently using (but NOT for everyone):

Accuro EMR summary and RxAll that being said, I am currently using Optimed Software’s Accuro but am looking into two others that I describe in greater detail below. Accuro is a good compromise if you are moving to an EMR as it is form-based. You have complete control over the screen layout which is a feature lacking in many other EMR systems. You can therefore make the screen look like your current paper chart. When I switched to Accuro, this was important based on the office staff I had at the time. I needed to ease the transition to a fully integrated EMR system as our previous EMR worked great for most scheduling, billing and importing ancillary test printouts, but was a bit awkward for chart notes, handling medications, and generating letters back to referring doctors. However, as you will learn with EMRs, there is ALWAYS compromise; no one system will be perfect for you. In the case of Accuro, the flexibility to create whatever fields you want, means that there are not enough pre-defined fields of data so you cannot easily generate reports or import prior data into new forms. In addition, every program handles billing and scheduling a bit differently and this one seems to require more steps than need be with those tasks as well as with generating the letters back to the referring doctors.

Other EMRs I’m intrigued by (and the decision of start-up vs established vendor):

ifa system glaucoma exam form

Ifa Systems AG has been doing nothing but Ophthalmology EMRs for over 20 years. Ifa is the world leader with integrating with ophthalmology equipment but requires many screens worth if data entry to do each exam. Accuro was good when my staff was afraid of an EMR but now that there has been staff turnover since I began to use it and the rest are very accustomed to an EMR, it is worth considering a change to the way more complex ifa system. The ifa system not only imports the printouts of ancillary testing devices but the raw data allowing you to ifa system graph intraocular pressuregenerate reports on any data.

There are of course trade-offs if opting for the ifa system. Rather than a simple monthly fee of approximately $300 per physician with Accuro, the ifa system has a monthly fee PLUS a very big upfront cost that can total thousands of dollars per workstation, depending on how many pieces of equipment are being integrated. Also, at least in Canada, the ifa system does not yet have billing (though it has it for most of the rest of the world. Hopefully, this is just a matter of time as it is commonly accepted that you should NOT get an EMR that is not a complete package…ie if it does everything but billing, look for something else.)

TeckSoft EyeVu summary screenA new company on the scene, TeckSoft, has created a program called EyeVu. Their initial goal was integrating ancillary testing devices as the ifa system does but they have an almost complete EMR package. They lack billing and, at least as of this past month, have stated that they have no intention of including billing as this would be too much work and suggest that there are many other billing programs out there.

TeckSoft EyeVu patient flowEyeVu has some of the best features of both Accuro and ifa, including a robust database of fields allowing for powerful search capabilities across all records, control over the exam form with the ability to just add an extra section on the fly when seeing a patient. They also have a unique visual way of handling patient flow, allowing you to see a floor plan showing where any patient is within your office as they flow through their pre-visit screen, ancillary tests, and examination. (The ifa system has a very good traffic manager that is less visual; Accuro has a poor traffic manager that fails miserably and was an afterthought.) Their pricing is much more reasonable than the ifa system and they still have the excellent integration of ancillary testing data.TeckSoft EyeVu advanced search

The biggest risk though with choosing the EyeVu, is that they are too new a company. Would you opt for a company like ifa systems AG with clients all over the world but a huge pricetag or a start-up with 7 clients and a lower price tag? Common sense would dictate going with the company that has the long proven track record; but the features found in TeckSoft’s EyeVu can make you through away common sense.

My next EMR article in the works:

My next EMR article will discuss the newly posted ‘meaningful use’ criteria being adopted by the province of British Columbia to go into effect in September 2010 for those seeking government funding for the right reasons: ie meaningful use.

"Does EHR in Canada also result in an explosion of words?"

2010-06-23T12:00:24Z

I received the following question from a colleague in the United States:

“In the US, payment is based on CPT codes which are determined by how many items are recorded in the examination.

This results in a system where “more is better”. A patient might simply have a small FB, yet the examination includes descriptions of the EOMs, lashes, optic nerve, mental status etc. (Not that in training they didn’t teach you that a good doctor did those routinely.)

With EHR, the ability to “default” normal items into the record can lead to 3 and 4 page eye examinations with elaborate descriptions of normal findings.

The ability to extract the pertinent material is hampered by the amount of useless verbiage.

My question is, “Does the use of EHR in Canada also result in such an explosion of words” or is the medical record more limited to what is useful?”

Here is what I said in response:

Explosion http://www.freewebs.com/tyler9j“Well, technically, no EMR should by default have all the normal findings checked but they can allow a simple click of a normal button for each part of the exam to complete each section. That being said, I guess it really depends on the type of report you need to generate with this overload of data. Like you said, it is great to prove that all key portions of the exam were performed, but not great to send your consult report as a 6 page document.

In my EMR letter generating template, I have things set with such phrases as ‘the anterior segment exam was normal except blah blah blah.” The finalized letter also spews out extra information and I can easily select what to include and the rest gets automatically excluded in the finalized letter. The bottom line is that I never send out a letter longer than one page long.

Not sure if that’s what you were getting at? Hope that can help.

—R”

How do you deal with meeting documentation criteria with your EMR? Do you have checkboxes for normal parts of the exam? Do you have some default items already filled in then change them if the exam differs from the defaults? Do your generated letters included EVERYTHING from your data entry form?

New iOS 4 accessibility options great for Baby Boomers

2010-06-22T14:54:48Z

The accessibility options now available on iOS 4 for the iPhone helps people read their screen more easily. Probably more important than the higher resolution on the new iPhone 4 device are the accessibility options in the upgraded OS that can be used on prior iPhone/iPod touch models. (As always, click on any thumbnail in this article to enlarge.)

Accessibility options iOS 4As someone who needs reading glasses, it can be quite challenging seeing the information on my iPhone if I don’t have my reading glasses with me or just have contact lenses on because I’m working out. There are two important accessibility features along with a modification of a built-in and often used app found in iOS 4 for your iPhone or iPod touch that are very helpful.

Accessibility iOS 4 font sizesThe accessibility features allow you to adjust the font size globally for the built-in apps and a 3-fingered screen tap (called Zoom in accessibility settings) to enlarge everything on the screen. The simple change to 20pt font makes enough of a difference for me to avoid eye fatigue but you don’t have to stop there; if you need to you can make the font size much bigger. So, skiing with your contacts on, you can still read your address book entries to call your ski buddy after you took a wrong turn. The Zoom function of using your 3 fingers to tap on the screen is a bit awkward but really does a great job of zooming in everything on the screen similar to the option-scroll-up in Mac OS X.

The feature that can also be very helpful in a built-in app is the camera! This was possible before with third-party apps like GoMagnify but now with the camera, when you tap on the screen, not only can you control what object is being focused upon and light balanced as was introduced with 3.0 but control your zoom as well. So, that can be helpful if you are just trying to read a price-tag when shopping or your lock to open up your locker at the gym.

Settings—>General to find Accessibility iOS 4To find your accessibility options, tap on Settings—>General—>then scroll way down to Accessibility. The features from the prior versions of the iOS such as VoiceOver, White on Black, Mono Audio are still there and another new one to Speak Auto-text so that you can be verbally warned of typos. Play with the settings and be sure to post any feedback such as useful tricks or omissions in the comments section below.

Telus deluded into thinking hosting HealthVault = patients access health records

2010-06-01T18:15:54Z

This morning the Vancouver Sun (@VancouverNews_) posted “Telus’s secure online service will let patients see their medical files” Nice idea but they are absolutely not capable of achieving anything like they talk about in the article any time soon. I discuss why….

HealthVault platformIt is a noble cause that Telus’s CEO Darren Entwistle has taken on to improve access to patient data having lost his father in part due to data access issues. Unfortunately, the Vancouver Sun article and the Telus Press release that it is likely based upon, makes it sound like all we need is Telus to start using Microsoft’s HealthVault and magically patients will access all their health records. At least when Apple promises some magic, they deliver something and make us think it is special. There is no way that Telus can deliver their magical solution as simply hosting a medium to access health records does not mean any data will be in the HealthVault.

To date, Telus has failed in providing high speed internet access to physicians in this province. The technology of course exists but it is too costly and they cannot just give their services away. So, building their pipe has to come first and can be achieved with time and lots of money. What cannot be accomplished anytime soon: getting the patient data entered. Infrastructure is needed and perhaps Telus is dedicated to making this happen but they need to be involved and somebody has to cover the massive costs in each piece of the puzzle. At least as a publicly traded telecommunications company Telus have a much better chance of making this happen than the government on their own with highly paid consultants.

The high speed data pipe isn’t working

Dialup telephone http://enli.co.cc/wp-content/uploads/dialup.jpegIn BC, there are a handful of Physician Information Technology Office (PITO) approved EMR systems that had to comply to certain standards in order for physicians to receive some incentive funding. One of these criteria to date has been the requirement that a dedicated internet line provided by Telus is used and that ALL patient data is stored off site with their system. I am fortunate to have never agreed to this as this system is not working out well for many of my colleagues. The dedicated Telus system is so slow that it is unusable. A medical office cannot wait 45 seconds for a keystroke to be transmitted in order to book a patient’s appointment or enter data; this process has to be near instantaneous. So, Telus, a telecommunications company, is failing at what they should know how to do…transmit data at high speeds.

We need fibre optic lines to all physician offices in all regions as a minimum requirement for this concept of health data access to even get started. Near instantaneous response to each keystroke to data being stored off-site is mandatory or there is no way physicians can use this system.

Entering the healthcare data; the missing link

Bottleneck http://www.fredberinger.comAssuming one day we have fibre optic data access to every health care provider in this province, how will the data get entered into the HealthVault? Yes, standard answers would be that either every physician uses the same EMR system or that their EMR system seamlessly exports the necessary data. There are enough differences in the data that is collected and in practice styles, that there is no one single EMR that can every work for every healthcare provider. As for exporting the data, if a pdf type copy of the exam form is sufficient, then probably any EMR can export their data but this is a terrible way of retrieving data when needed. This is the part of the access to healthcare information that I don’t see happening in my lifetime.

To summarize, the steps that can be achieved but are still many years away have to do with just laying down high speed data connections to all healthcare providers. The technology exists but is costly for retrofitting any existing buildings. Having a medium for data storage such as the health vault will be a good next step once we have high speed access to save and retrieve the data to it. Getting the data from healthcare providers into the HealthVault is the biggest challenge is it takes more than just money; it will take so much cooperation between doctors, EMR vendors, the government, telecommunications companies and privacy advocates that it will be near impossible to achieve.

Value of the iPad in medical care?

2010-05-31T12:00:00Z

iPad with keyboard dock in Medical settingBelow I have copied my comments and made some corrections to what I posted on 29May2010 at CanadianEMR.ca iPad Where is the Value about how I have been using the iPad so far. I have taken the liberty of adding some helpful links to the apps that I referred to in my comments that I made at CanadianEMR. I thought it might be of interest to readers of my blog so am also posting it here. Please check http://canadianemr.ca too as they always have great articles in this field.

I have been fortunate to be using an iPad for the past few weeks, having bought one in the States to stay ahead of the curve. I agree that it will have some great medical uses though this is still in its early phases.

For starters, the EMR that I use, Optimed Software’s Accuro, has a mobile version. This has been very good on an iPhone and makes great use of the increased screen real estate of the iPad. From what I understand, the company is also hard at work creating an actual iPad app aside from its excellent java based mobile app.

OCT Browser iPad appOptic imaging devices such as the Ocular Coherence Tomography units, will have iPad software. There is already an OCT Browser available in the app store created by the good people at the University of Pittsburgh Medical Centre Dept of Ophthalmology. Not a surprise as the team there developed the OCT when they were in Boston a decade or more ago. I am sure that others or even they will develop similar viewers for the scanning laser ophthalmoscope imaging devices such as the Heidelberg Retinal Tomogram.

Although I have yet to install it, there is an Air Display app that allows extending your computer’s screen onto the iPad. I just realized today that this means I can move the visual field or HRT viewer onto the iPad’s virtualized screen and hand that to the patient even if there is no native viewer app yet. I will try this next week.

iAnnotate for PDF files on iPadThe other uses of the iPad for me have just been much better access to news sources as news apps are getting iPad optimized. A favorite is Instapaper Pro which allows me to save any web page into my Instapaper account to view later at my leisure via the Instapaper app. Even the paid version though has a limit of only 250 articles that can be saved and they make it clear in their terms of service that it is only meant as a temporary means of storage of your information. Evernote can be used in a similar way and works well on the iPad and iAnnotate is an excellent PDF viewer that even allows you to add comments and highights to your PDF files that can be saved back in PDF format on your computer or be emailed from the iPad. With iAnnotate, Instapaper Pro and Evernote there are many excellent mobile educational tool for continuing professional development.

This is only the beginning of a very bright future for the iPad in medicine.

Is the Glaukos iStent the next big thing in Glaucoma Surgery?

2010-05-25T12:00:17Z

Glaukos iStentThere’s a new device available to help in the surgical management of patients with glaucoma: the Glaukos iStent. After implanting a pair of these in each of three patients, here are my initial thoughts along with links to some recent publications. I have also included a video of the second patient in whom I used these implants and several recent references on the device. The iStent was approved in Canada in April 2010 but still awaits FDA approval in the United States.

The ideal patient for this device is a patient who is scheduled for cataract surgery in whom their glaucoma is not under ideal control. For example, if a patient requires three glaucoma medications already to keep their glaucoma under control or is not quite controlled on medical therapy. This device has a very good chance of drastically reducing a patient’s dependency on glaucoma medications to achieve intraocular pressure (IOP) control when performed at the time of cataract surgery. I would still be inclined to recommend a trabeculectomy without cataract surgery as a primary procedure in a patient, even if they have a cataract present, if their glaucoma is not ideally controlled on current medical therapy.

In order to perform this type of surgery, the ophthalmologist needs to be VERY comfortable with performing gonioscopy to clearly see the trabecular meshwork. The view in the video is an accurate depiction of what I was seeing when performing the surgery. You will notice when the second stent is being placed that the act of inserting the device was enough to obscure the view. There is no point in even opening the packaging for the iStent if the angle is not CLEARLY visualized. As when using a Sussman or Zeiss-type goniolens in the office setting, it is easy to distort the cornea if you press too hard with the operative goniolens, rendering the view too blurry. If you are an ophthalmologist and are considering performing this surgery, make sure you are very proficient with gonioscopy in the office with an indentation lens such as the Sussman or Zeiss.

There will be bleeding as the blood contained in Schlemm’s canal makes its appearance upon iStent insertion. If the stent does not go in without resistance and does not cause a small amount of bleeding, then you are probably in the wrong plain. The video clip above was of the second case I performed. On my first case, the tip of the stent touched the trabecular meshwork when I was introducing the device into the area of the angle which resulted in instant bleeding and obscuration of the meshwork. I was able to inject additional viscoelastic material which pushed the blood out of the way to allow proper visualization. It is important that before impaling the angle that you touch it with the flat edge of the stent or its angled corner near the insertion probe, bother of which are not sharp, in order to gain your perspective on where the angle is located. Due to the optics of the system, objects may be closer than they appear and at a slightly different orientation. You ultimately enter the meshwork with the stent at what looks like 1/3 of the way down from the top of the angle which actually ends up being the middle of the trabecular meshwork.

At the one week mark on the three patients, two patients have pressures in the mid-teens and are not on any glaucoma medications. The patient who had bled on initial introduction of the stent into the eye and was on 4 glaucoma medications prior to the surgery, required one of their glaucoma drops to be resumed in order to regain better IOP control. I will update this article in the weeks ahead with more details of the post-operative course of the eye pressures.

Intraocular trimming of Ahmed glaucoma tube

2010-05-18T17:09:07Z

Trim Ahmed glaucoma tube tip within eyeThis aphakic patient presented with elevated intra-ocular pressure many years after Ahmed Glaucoma Valve implantation performed by a colleague of mine. Some vitreous had found its way into the tip of the tip that extended beyond the pupillary margin. As these glaucoma tubes are, as Dale Heuer has referred to them, divining rods for vitreous, it is not surprising that this happened. Watch this video to see how I ended up dealing with this.

Now 3 weeks since this surgery and her pressure is 18 mmHg on only the prednisolone drops for inflammation whereas it was 54 prior to surgery on glaucoma medications.

Don't move to EMR if sole reason bonus $$ from government; adopt for right reasons

2010-05-06T22:15:54Z

If you adopted an Electronic Medical Record to take advantage of government funding, then you have made a big mistake, not to mention having abused public funds for personal gain. An EMR SHOULD be used to help improve the quality of care for your patients. For the most part, such systems do not save you time during your patient encounters and can be heartbreakingly painful to set up for your practice. That being said, it appears that a number of my colleagues have made the move to an EMR so they could get the government incentive money. Why would anyone do this?

Our province has a government funded initiative in order to help compensate physicians for the transition to Electronic Medical Records (PITO.) By covering 70% of the cost up to a set maximum, the plan is meant to help compensate for the burden of making the transition and to help improve healthcare by setting some standards for data collection with the longterm goal of accessible data throughout the province regardless where the patient seeks care.

As is becoming the pattern in other provinces, these initiatives appear to be money pits costing more than planned due to poor management that ultimately fail to meet any of the set targets. As for the goal of the patient showing up in some area of the province other than their own family doctor’s office and being able to access their data - nice dream and not likely in our lifetimes, even though the technology all exists today.

In talking with my lead IT consultant, it turns out that many of the medical practices which he supports may have signed on to the idea of an EMR for the government cash grab! It is hard to imagine the cost of those critical first few months of decreased productivity when implementing an EMR is worth the approximate $7,000 per year cash incentive from the government. Since the governments are doing this to get the ball rolling, it is safe to assume that this funding will not last forever and within a couple of years they will announce no more annual cashback. Will my colleagues really just go back to paper if this happens?

You need to adopt an EMR for the right reasons; cash incentive from your government is not one of those reasons! Some of the right reasons:

Easier access to your data from prior visits for each patient
Automatic appearance of lab results directly into each patient’s record (saving time wasted searching for lost results)
Access to patient records remotely (you get a call from a house officer or on-call doc about one of your patients and can pull out your patient’s chart on your handheld device - mine works on the iPhone)
Confirm outcomes of treatment to a given patient or even all patients you see with similar conditions/treatments
Generate consult letters back to your referring doctor

Note how abusing the government health care funds by adopting an EMR for the cash incentive is not on this list!

BC Government's dangerous new health regulation will blind us

2010-04-28T20:06:01Z

The BC Government’s change in regulation no longer requiring routine eye exams for glasses to come into effect on 1May2010 is so dangerous that I am posting this link to an extensive article about it for those who may only be visiting my Glaucoma/EMR blog and not my Optom/EyeMD blog.

Please read and help in any way that you can to let our government know the importance of routine eye examinations in preventing permanent visual loss.

Glaucoma Consults: distinguishing physiologic from abnormal cupping & which end-stage eye to operate on first

2010-04-27T22:28:58Z

Friday April 23, 2010

Please note that all images in this article can be enlarged by clicking on them.

Case 1:

10 yo boy #glaucoma #consult b/o cupping; nerve diameter bigger than avg so physiologic. How often to follow?

This young man was referred by his paediatric ophthalmologist with asymmetrical increased optic nerve cupping for an opinion as to whether he might have early glaucoma damage. He had already had 3 HRT scans over the past couple of years to help establish a good baseline assessment for future comparison. Another reason for some concern was the family history of great aunts and great uncles who have had glaucoma, one of whom was blind as a result.

Visual acuity was 6/6 in each eye with current very small mixed astigmatic spectacle correction with IOP readings of 18 mmHg OD and 16 mmHg OS at 0915hrs and CCT readings of 558 ums OD and 552 ums OS. I was not terribly worried about the optic nerve appearance which I described as “overall increased optic nerve diameter with slight asymmetry of cupping but ISNT rule obeyed and not notched” out in my chart.

HRT OD Case 1 23Apr2010HRT OS Case 1 23Apr2010

Notice on the HRT scans that the overall disc and cup areas are greater than normal, but the rim areas are at the high end of normal. If there really were ‘increased cupping’ as we often refer to glaucoma damage, then we would see an abnormally small rim area as the nerve gets taken over by its cupped out portion. This is physiological increased cupping of the optic nerve.

What would your follow-up plan be for this patient? What do you think of the family history and would this effect your management?

Case 3:

73 yo WM #glaucoma #consult end stage left eye, mod adv right; IOP 26 on meds - which eye for Trabeculectomy 1st?

This is a discussion that I end up having too often; glaucoma surgery on the eye that is almost blind so the last bit of vision is not snuffed out or on the less damaged eye so that it doesn’t get worse. There are pros and cons to each approach and the answer is very much individualized to the patient.

Visual Field OS Case 3 23Apr2010 end stage damageVisual Field OD Case 3 23Apr2010 near end stage damage

This patient was referred by another ophthalmologist for surgery due to abnormal visual fields, progressive optic nerve damage with a note that the IOP was still elevated in the left eye after a recent change in glaucoma medications. He is taking Duotrav, Lumigan in addition to 10 other systemic medications for cardiovascular disease, bipolar disorder, colitis, and Parkinson’s-like symptoms from prior meds.

Visual acuity was 6/15 OD and 6/21 OS without correction, improving to 6/12 OD and 6/7.5 OS with multiple pinhole correction. His corneas were moderately dry, anterior chambers of moderated depth, and 2+ nuclear sclerotic cataracts were present. Eye pressure readings were 24 mmHg OD and 25 OS with CCT readings of 532 ums OD and 527 OS. Angles were open to at least the posterior trabecular meshwork and both optic nerves extensively cupped out.

Given this degree of optic nerve damage, the eye pressure is not ideal in either eye. Using the Advanced Glaucoma Intervention Study (AGIS) findings, we really want the eye pressures to never be 18 or higher in either eye if this can be achieved safely. Going back therefore to the initial question, which eye would you operate on first?

Case 4:

44 yo XXY #glaucoma #consult14D myope, increased cupping, normal disc diam, IOP 16, on Atenolol (systemically Tx’ing IOP?) N VF. Glaucoma?

HRT OS Case 4 23Apr2010

HRT OD Case 4 23Apr2010

This patient was referred by their optometrist because of increased cupping of his optic nerves, more so in the right than left eye. Systemic medications include ASA, gemfibrozil, propafenone and atenolol. He had a cardiac conduction defect that was ablated at one point but his AV-node was damaged during the ablation.

Visual acuity was noted to be 6/7.5 OD and 6/9 OS with his current spectacle correction of -11.75 -0.50 x 043 OD and -14.25 -0.50 x 153 OS. Trace cataract findings were present, IOP readings 15 OD and 16 OS at 1015hrs with CCT of 511 OU. Angles were moderately pigmented with a clear view to the ciliary body band OU. Optic nerves as seen in the HRT nerve scans and Visual Fields as attached are normal.

Compare these HRT findings with the first patient that had the physiologic increased cupping. Notice here how the rim area is impacted and therefore, despite the normal Visual Fields, this patient likely does have glaucomatous damage. However, he also has been taking a systemic beta-blocker, Atenolol, which means he has been treating his eye pressures by the heart medication.

Visual Field OS Case 4 23Apr2010

Visual Field OD Case 4 23Apr2010

The following two cases were tweeted as per below but there is enough material to discuss with the above cases for this week so no additional material is provided.

Case 2:

44 yo hispanic M #glaucoma #consult b/o family Hx; increased pigment angle, discs very normal. Plan?

Case 5:

83 yo WM mentally challenged#glaucoma #consult IOP asymmetry (23 vs 18) w/ corresponding disc asymmetry. Best Tx option?