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ortrait of an Electronic Optometric Office

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“It’s awesome,” a receptionist at PlanoEye Associates says of the paperless op-tometric practice in which she works.

ractice owner Kim A. Castleberry, O.D. isnly slightly more reserved. “Going back to aig Chief tablet and a number 2 pencil woulde like going back to the Stone Age,” he says.n a conventional practice with paper-basednformation management, “you see half theatients with twice the time, effort, and en-rgy,” he adds.

The overwhelmingly positive assessment oflectronic health information technology (HIT),rom one of the first optometrists in the nationo actually implement a paperless practice,

ay come as welcome news to optometristscross the nation who soon may be investigat-ng the potential benefits of electronic practiceor themselves. Declaring a “Decade of Healthnformation Technology,” the US Departmentf Health and Human Services (HHS), with theull support of the Bush Administration, hasegun an effort to establish a national elec-ronic health record network over a 10-yeareriod. (See “Practices Strategies” October004, “HHS Launches Decade of Health Infor-ation Technology.”) Under this program, as

nvisioned by HHS, every American will haven electronic health record (EHR), whichealth care practitioners and institutions willccess when providing care. That means virtu-

ob Pieper is the senior editor for Practice Strategies. Opinions

Paperless practitioner Kim A.Castleberry, O.D., finds his electronicoffice has delivered efficiency, costsavings, and an enhanced patientexperience as promised.

hxpressed are those of the author and not necessarily those of themerican Optometric Association.

OLUME 76 / NUMBER 10 / OCTOBER 2005

lly every health care provider in the nation—ncluding optometrists—will be required to im-lement electronic patient record keeping.The national EHR program complements

ngoing efforts by government and private in-urance plans to encourage electronic billingnd claims processing. Many close to the HITffort believe that with clinical record keepingnd billing functions computerized, mostealth care practitioners will find it simplyakes sense to take the few final steps neces-

ary to establish a fully electronic practice—sing electronic diagnostic instruments and im-ging devices to download digital data directlyo patient records and electronic messaging tossue prescriptions and laboratory orders. (SeePractice Strategies,” September 2005, “Movingoward the Paperless Practice.”)Based on almost 15 years’ experience in

lectronic practice, Dr. Castleberry believeshey will be headed in the right direction.

HHS—and many private health insurers—iew electronic health information technologys a cost-cutting measure, potentially importantn preventing costly health care errors andraud. Patients—who will be encouraged to ac-ess their own EHRs—will be able to assesshemselves for proper preventive care and

igure 1 Plano Eye Associates.

ealth risks. This will lead to increased aware-

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ess of health issues, better lifestyle choices,nd an overall improvement in the nation’sealth, HIT proponents say. However, healthare practitioners may find their own reasonso implement electronic HIT including in-reased practice efficiency, substantial cost re-uctions, and an enhanced patient experience,ccording to Dr. Castleberry.

Located in a Dallas suburb, his Plano Eyessociates is a 3-doctor (2 full-time equiva-

ents), $2 million-a-year, full-scope primaryare optometric practice, with a full-servicenishing laboratory, 15 examination lanes, a,000-square-foot building, and records for0,000 patients. Established in 1983, Plano Eyessociates was a conventional paper practice,sing some electronic information technology,ntil the mid-1990s when the practice wentully electronic using a DOS-based OfficeMateractice management system (OfficeMate, Ir-ine, CA). The practice converted to a Mi-rosoft-based OfficeMate system last Novem-er.

he Electronic Exam“It’s much easier for the patient,” says the

ractice receptionist. “Even a new patient doesot have to fill out a mountain of paperwork.atient information is obtained by staff andntered in the electronic patient records whileatients are still in the reception area. Insur-nce cards, likewise, are scanned and entereds part of the electronic records while patientsait for their appointments. Staff becomes

killed at obtaining any additional informationecessary as patients enter the examinationoom,” Dr. Castleberry confirms.

On entering the examination room, the prac-itioner calls up the patient’s file on a monitornd takes a minute to review it before conduct-ng the examination. Staff is not required topend time pulling patient records from theffice files. All ophthalmic instruments are in-erfaced with the practice information process-ng system. Results of refraction, lensometry,nd other tests are automatically placed in thelectronic patient record and reviewed by theractitioner on the monitor. The practitionernters examination notes in the electronic pa-ient chart by selecting prewritten texts, in-luded with the practice’s OfficeMate Exam-riter program, and edits them if necessary to

eflect the exact findings of the examination.

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When the examination is complete, the prac-itioner counsels the patient while still in thexamination room. The information processingystem, meanwhile, automatically generates arescription—as well as any referral letters orther documents required—based on the infor-ation in the patient records. Lens prescrip-

ions are electronically sent to the office labora-ory or dispensary unless otherwise requestedy the patient. Paperwork associated with thexamination is largely completed by the timehe patient and practitioner leave the examina-ion room. Closing the electronic patient recordefiles it in the practice’s data storage system.

Staff members are not required to updateatient files, prepare referrals letters, or filensurance claims based on the practitioner’sotes after an examination. “We do not have toead the doctor’s handwriting, which is nice,”he receptionist says. Nor must they spendime returning patient charts to filing cabinets.laims for services are automatically codednd sent to the appropriate third-party payer.bill for any deductibles or copayments is au-

omatically prepared. Staff responsibilities afterhe examination generally involve dispensingyewear, collecting any additional fees, andssuing a printed prescription and receipt. Evenn a paperless practice, “we use some paper,”he receptionist notes.

enefits of EHRs“The main difference (in an electronic prac-

ice) is you simply do not spend time handlingaper,” Dr. Castleberry observes. And most

igure 2 Examination lanes at Plano Eye Associates feature fullyautomated, motorized refractors that feed test results directlyinto the patient’s EHR. Test results are displayed on a

computer monitor in the examination lane.

VOLUME 76 / NUMBER 10 / OCTOBER 2005

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ractitioners may not appreciate just howuch time and effort that takes.A paperless practice can function with half

he full-time equivalent employees required forcomparable paper-based practice, he main-

ains. That can significantly reduce staffingosts. Plano Eye Associates employed 2 staffembers simply to handle patient records.hat is no longer necessary, Dr. Castleberryays. Billing and claims filing, a major staffunction in almost any practice, is virtuallyliminated as a staff function in an electronicractice, as is record transcription.Moreover, electronic records can reduce of-

ce overhead beyond simply reducing costs foraper and office supplies. When Plano Eye As-ociates’ new office was built 5 years ago, Dr.astleberry found he could eliminate 500 feetf space that had previously been required foraper patient records. “And as you know,pace is money,” Dr. Castleberry notes.

In addition, the electronic office can achieveemarkable improvements in billing efficiencynd cash flow. “Procedures are automaticallyoded and billed to insurance carriers with aignificant reduction in billing errors, paymentow received consistently within 7 to 14 days,nd virtually 100% reimbursement on cleanlaims,” Dr. Castleberry reports. “I still checkur EOBs (explanation of benefits), just to seehat we are doing and (last month) found

00% cleared. We used to be happy to get 60%o 70%, and we were happy to get it in 60

igure 3 Preliminary examination rooms at Plano Eye Associates in-clude automated lensometery, Marco 3D Wave corneal wave-front analysis, and OptoMap retinal examination, with allresults fed directly to the patient’s EHRs and displayed on themonitor in the pre-examination room.

ays.” F

OLUME 76 / NUMBER 10 / OCTOBER 2005

Electronic practices can easily accommodateew diagnostic technology, much of which isesigned to interface with digital record-keep-ng systems. An examination at Plano Eye As-ociates includes specular microscopy, retinalhickness analysis, OptoMap, wavefront, ultra-ound A scan and B scan, visual field, and pu-

igure 4 Patients in the pre-examination room can appreciate the levelof high-tech eye care being provided, as they see their testresults displayed on the monitor as well as posters describingthe various technologies being used.

Examination results can be accessed on all 3 terminals in the

igure 5 Plano Eye Associates dispensary.

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ilometry—results of which are all accepted byhe practice’s ExamWriter record program. Theesult is a very complete eye examination, Dr.astleberry notes.

rawbacksAs with just about everything in life, Dr.

astleberry acknowledges, electronic practicean have its drawbacks such as occasional in-bility to access records. His practice was re-ently without access to its records for a-hour period after a nearby business wastruck by lightening, and the power wentown. However, such incidents are relativelyare, Dr. Castleberry reports. “The only otherignificant period of time the practice has goneithout access to its records in the (nearly) 15ears it has been paperless, was a couple ofays, when the system became infected with airus and froze,” he recalls.The potential for loss of access to records,

owever, makes proper backup of files ex-remely important for an electronic practice,r. Castleberry emphasizes. He recommendssing offsite storage services that downloadractice files via the Internet and store them insecure databank at a remote location. Planoye Associates contracts with Data Health Ser-ices, which automatically downloads the prac-ice files and stores them at 1 AM each day. “Inhe morning (when you come into the office),ou get an e-mail saying your files are storedafe and sound,” Dr. Castleberry says. He re-alls some instances in the past when he haselied on himself or his staff to backup records

igure 6 Kim Castleberry, O.D.

nd found “you may think you are backing up w

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ecords properly when you are not.” In the onease in which the practice information systemroze, Dr. Castleberry discovered the officeomputers had been infected with a virus andwe had actually been backing up a virus on airus.” The hard drive from the practice’s mainomputer was sent to OfficeMate for a day andhalf to have it “cleaned,” and the practiceas soon back in operation. However, the inci-ent serves to illustrate the need for good virusrotection, firewalls, anti-intrusion software,nd other computer security measures, Dr.astleberry says.Conversion to electronic records can be

ard, Castleberry admits, particularly on staff.e lost 3 long-time staff members “who just

ould not adjust to the computers,” during hisransition to paperless practice. “During therst year you have to pull a file for every pa-ient, transferring basic data to the electronicle, and then ‘check’ the EHR to note that aaper record also exists for the patient. Theecond year, you pull half as many files. Thehird year, you pull paper files rarely. Theourth and fifth year, you pull none at all,” Dr.astleberry says. After 5 years of electronicractice, Dr. Castleberry moved his paper filesff premises to a storage facility and, after 10ears, destroyed the old paper records “realiz-ng that I had not consulted them in 5 (years).”

There are also some adjustments for theractitioner. “The first examination is the hard-st,” Dr. Castleberry says. “Part of it is that its hard to walk into an examination room with-ut a chart. An examination actually takes aittle longer because all of the patient consulta-ion will be accomplished in the examinationoom. I may take a few minutes to edit a refer-al letter with customized text.” However,most practitioners have a stack of files onheir desks to finish at the end of the day. Ion’t,” he adds.Paperless practice can be highly beneficial—

ven essential—for a high-volume, multidoctorractice like Plano Eye Associates, Dr. Castle-erry says. “But really, for all practices,” hedds. “My wife, a self-described technophobe,ust went paperless when she built her newractice in Denton (Texas). The first examina-ion was hard. By the end of the day she

ouldn’t be without it.”

VOLUME 76 / NUMBER 10 / OCTOBER 2005