Some ophthalmology practices have implemented EHRs only to find out that their existing office equipment has difficulty interfacing with the EHR. In some instances, the solutions to these connectivity issues can be costly, so, before purchasing a system, make sure the vendor has a plan for connecting all of your current devices, or consider increasing your EHR budget to purchase new equipment.

Instrument Connectivity

Most EHR vendors ask for an equipment list before installing the EHR system in your office in an attempt to foresee any connectivity issues that might arise. “Medflow, our EHR vendor, did a really good job of analyzing each diagnostic piece of equipment in advance and telling us what would work and what wouldn’t work,” says Mark Prussian, CEO of the Eye Care Institute in Louisville, Ky.

Mr. Prussian says some instruments are simply too old to be connected to EHRs cost-efficiently. In these cases, information can be printed and scanned into the EHR, or new equipment can be purchased. “We had an older piece of Zeiss equipment in our office, and we decided that it wasn’t worth the effort to attempt a custom program for one piece of equipment. We decided, as part of our budget for EHR implementation, that we would go ahead and replace that piece of equipment,” he says.

Conversely, Jim Messier, vice president of sales and marketing at Medflow, says, “There are many old devices in the field, but there really isn’t any device that we haven’t been able to take information off of and store it in the EHR record.” For example, if a practice has an older Orbscan, Mr. Messier says that the vendor would essentially disable the color printer on the device. Instead of a printer capturing that information, the information would be sent to a network PC that is connected directly into the EHR. Rather than the result being printed on paper,  it would be converted to a file that would then be stored to the EHR chart.

“It all comes down to cost,” Mr. Messier says. “These interfaces can be $1,000 to $1,500, so if a practice is only using the device once a week or three times a month, then it may not warrant the expense, in which case they would continue to print out the results and scan and store them in the image management portion of the EHR. They would still have the ability to put it into the record and view it from within the electronic chart for comparative purposes.”

Jeff Grant, a medical practice management consultant with HCMA, agrees that equipment interfacing is an important issue and notes that it can be especially challenging in ophthalmology. “Connecting the devices to the EHR is one of the biggest hurdles outside of just implementing an EHR, because there is so much diagnostic image-specific equipment in ophthalmology,” he says. “Interfacing to all of the diagnostic equipment is a major issue, especially for a practice that has multiple locations where data are being pulled from a satellite to a central server.” He cautions ophthalmologists about allowing vendors to provide assurances without proof. He recommends that physicians ask vendors to show them how certain equipment will connect to the EHR.

Mr. Grant notes that there are two ways to capture information: One is to capture what traditionally would have been printed, such as OCT output; and the second  is to capture raw data and raw images.

“Capturing raw data is a more complicated and more expensive way,” he says. “Some vendors can do that, and some vendors cannot. With older equipment, in most cases, if you can print it, it can be captured and imported into the EHR.”

According to Karen Perry, OD, FAAO, Zeiss Humphrey visual field analyzers can be challenging to integrate into an EHR without purchasing the client-based Forum software from Zeiss. “We export the visual field data to a printed document or pdf and import the image into the software,” explains Dr. Perry, who is in private practice in Orlando, Fla.

Another option is a third-party image management solution. Topcon has a product called EyeRoute Synergy Ophthalmic Data Management System, and Carl Zeiss Meditec has a product called Forum. According to Mr. Grant, they are very sophisticated and very pricy. However, they can capture data from many different pieces of equipment, and then the EHR vendor just connects to that system.

“Both of those vendors do a nice job with displaying a lot of images in a thumbnail format, and both vendors have tried to do some pricing strategies to make it less expensive,” Mr. Grant says. “However, mainly larger practices and multisite practices seem to be using these products. The typical one- or two-doctor single-site practice is probably not going to go that route because of the price.”

He notes that the more offices and more pieces of equipment a practice has, the more complex the issue becomes. “If you have five devices at five different locations, you have to interface 25 pieces of equipment,” he says. “These are the offices where an image management vendor may be acceptable because it may cost $25,000, which is $1,000 per piece of equipment. A smaller practice may pay a base price of $8,000 or $9,000 so they don’t get the low per-piece price that the larger practices would get.”

According to Mr. Prussian, AMO/Visx considers its diagnostic instruments and excimer lasers to be proprietary, and they do not work with EHRs. “We knew this ahead of time, so we scan in the results of  these instruments. We thought that the solution was fair because AMO/Visx disclosed it in advance,” Mr. Prussian adds.

According to Mr. Messier, the device connectivity situation will continue to evolve over time. Hopefully, in the near future, standards will be developed to make interfacing easier. DICOM, or digital imaging and communications in medicine, is the standard for distributing and viewing medical images, regardless of the origin. “This standard was created in radiology years ago and was adopted by cardiology and orthopedics. For the past six years, the AAO has been pushing IHE (Integrating the Healthcare Enterprise), which has to do with creating standards for true plug-and-play with devices, medical records, and practice management systems,” he says.

Mr. Messier notes that Zeiss is now fully engaged with DICOM, so new Zeiss devices are equipped with tools and software so that these machines can plug directly into a network and not require any other additional hardware or software. “The EHR can communicate directly with these devices or, in the case of Zeiss, the Forum software,” he says. “That’s the best solution possible. It is getting easier, and it is getting better. With DICOM, there is a much better integration. The doctor can create an order for a visual field test, which can utilize DICOM messaging and send the order and demographics right to that modality. The technicians don’t have to enter demographic information any longer on those machines. The result of the test is automatically stored back to the EHR on the image server, so DICOM really does more than just connect the device. It creates a great communication protocol and workflow, allowing the doctor to directly connect to ancillary staff, who need to do the work, and to the device, which can create the demographic entry automatically. This is the optimum workflow.”
Dr. Perry adds that Compulink now has implemented an Open Office interface. “This program has a new wizard designed to help customize letters, reports, and other documents. It is a leap forward, because it doesn’t require the purchase of a Microsoft Office license for every computer,” she explains.

Internet, Network Connectivity

Another concern for moving diagnostic data from a modality to a server (whether it is in the cloud or in your office) is connectivity to the Internet or wide area network.

If you have a cloud-based server or a central server in one office with satellite offices, your ability to access your EHR information and to store diagnostic results is solely dependent on your Internet connection and the bandwidth provided. “In a cloud-based environment, you are 100 percent reliant on your Internet connection to be up 100 percent of the time,” Mr. Messier says. “Otherwise, you are out of business. If you are in a client-server environment and you have multiple locations, these remote locations are dependent upon Internet connectivity. If you are performing visual fields and HRTs and OCTs remotely, that information has to store back to the primary server, whether it is cloud- or client-server based. This is where the bandwidth requirement must be sufficient to be able to store this information up to the server, so that if the provider orders an OCT and I am in my remote location, the network infrastructure must be able to support the uploading of those results to the server in a matter of minutes, so I can then see the results of that test in my exam lane without any kind of latency.”

He frames the issue this way: Do you have the appropriate bandwidth to take a 2 mg to 100 mg file and store it back to your server, whether it is cloud- or office-based? “The challenge for physicians is to order the test, have the technician efficiently get the order and complete the test, store the results back to the server, and then access the results in the image management portion of the EHR to make informed decisions, and then move forward with a treatment plan,” he adds.

Mr. Grant agrees, noting that two of the big issues with cloud computing are connectivity to the Internet and added difficulty connecting to diagnostic equipment. “With cloud computing, if you lose your Internet connection, you are totally and completely down. You have no access to your data whether you have one office or 10. Additionally, with cloud computing, connectivity to the diagnostic equipment is even more difficult. You don’t even know where the server farm is that you are connecting to. This is one of the reasons why cloud-based systems haven’t gotten a very big foothold in ophthalmology yet,” he explains.

Dr. Perry notes that her office chose to go with an in-house server for just these reasons. “We looked into cloud computing, but at the time we looked, the diagnostic equipment interfaces were very slow, particularly with imaging,” she adds.

Mr. Prussian says that his office has experienced many more difficulties with Internet connectivity than with device connectivity. “Our biggest problem with connectivity is the actual Internet connection that is needed from wherever the server is located to wherever the doctors are seeing patients,” he says. “That is where our connectivity issue has come in. Regardless of the type of Internet service that you have, Internet services fail, whether it is due to a power line being cut by work crews or it is due to system upgrades or glitches in networks. When this happens, we stop seeing patients for about five minutes. Then, we revert to paper. This has never happened due to our EHR system; however, it has happened four times in the past year and a half due to Internet service providers not delivering a signal.”

He notes that the only solution to this problem is to have duplicate Internet connections, possibly one with a phone company and one with a cable company. “It is a costly answer, but it is an answer. It’s not one that we have chosen to take yet,” he adds.

The Future

Because of meaningful use requirements, EHRs are clearly the way of the future. As they are implemented in more practices, technology will continue to improve. 

According to Dr. Perry, “The ability to communicate and share testing results and data in real-time with patients is significant. The next step is to develop to a level where we are communicating and sharing information in real time through a secure portal with our colleagues. Instead of a patient completing patient information forms at every provider, we will have access to patient health information and testing results from a secure portal, thus providing better continuity and quality of patient care,” she says.

Mr. Prussian agrees. “The theory of EHR is wonderful, but I think that the federal incentives were too soon in that the technology for offices, hospitals, and labs to talk to each other just isn’t there yet. You really can’t share your data easily with other doctors. I believe that we are several versions of software away, and therefore several years away, from vendor A’s software being able to interface with vendor B’s software,” he says.  REVIEW