EHR use on an iPad is not ready for prime time.  This opinion is being offered by a technology geek.  Our home has six iPods, two iMacs, a MacBook, an iPhone and two Samsung Delve phones, and a Dell laptop PC, plus a wireless router, back-up hard drives, and a printer/fax/scanner.  Our practice has an automated phoropter, computerized tonometry instruments, a pachymeter, topographer, and retinal nerve fiber layers analyzer, plus our trusted old visual fields machine and a brand new aberrometer.  Today’s optometry practice can drown in technology and that can cause some ODs concern if they are not tech savvy.

When doctors consider EHR technology, they don’t want to be anchored to a computer to care for a patient - we often hear about desires for user simplifications like touchscreens and voice recognition and portability of computers.  In the last month, I cannot begin to count the number of questions about EHR compatibility with the new iPad.  While it is not easy to appear against a cool new technology, EHR is best managed by sturdy, powerful desktop computers.

Practically, doctors do not think completely enough about the issues of office hardware when they adopt EHR.  When our web-based software product was new, we told doctors that all they needed was a PC or Mac with a 17″ monitor and a high speed internet connection, and that was a mistake.  While our original recommendation was true, the internal guts of the PC or Mac made a huge difference in user experience.  We evolved the standards to a point of “recommended” standards instead of “minimum” requirements.  Lots of memory (RAM), a large high-definition screen, a keyboard with a full numberpad, and a high speed processor significantly improve the user experience.  Rarely can you get those features in portable machines — laptops, tablets, and now, iPads.

Doctors think that their EHR implementation will be easier with a computer that can be carried under one’s arm like a paper chart, that can be placed on one’s lap to retain the traditional doctor facing position to the patient, and that allows the electronic record to be along for the ride no matter where the doctors goes.  But portability must be put well down the list of priorities when considering EHR hardware.

Here’s why:  data entry.  Portable computers do not provide as efficient data entry means as desktop computers.  Can you enter data on a tablet easier than a desktop computer because it has a touchscreen?  Some you can, some you can’t.  It looks cool to see someone demo EHR on a touchscreen but not all data is entered effectively in that way.  Can you enter data into an iPad easier than a desktop computer?  I don’t think so, unless you carry around a Bluetooth keyboard or buy a bunch of docking stations that include a keyboard.  And don’t forget about the other issues with portable devices — you have to plug them in to keep the battery charged and batteries do run down based upon intensity of use, and portable computers are at risk of breakage when dropped, and they are sensitive to Wi-Fi connection reliability and speed.

I’m telling optometrists to not be distracted by the stories about how great it might be to have an EHR on an iPad because the iPad does not yet offer easy data entry capability.  Doctors type into EHRs regardless of the number of dropdown menus, autofill fields, or other cool data fill features.  That means that data entry will need to be done by pecking on the iPad’s flat screen keyboard, which is nearly impossible.

Test it yourself; go to an Apple Store today and pick up sample iPad.  Hold it like you want to hold it while sitting on your exam stool - you’ll find it’s not a laptop device, so it needs to be put on the counter in the exact same place you’d put a desktop computer.  Then test the data entry capabilities — go to the Safari browser and type in www.mapquest.com and start typing in a search for directions from your home address to your office.  It’s an exhausting experience that will prove my iPad-is-not-for-EHR point.

When you are done testing an iPad, you might very well buy one for browsing the web or checking email at home.  But you will not come away thinking that an iPad is an efficient EHR device.  This geek believes there will be a day, but it’s not today.

The daily practice of optometry is really quite pleasant.  Compared to many other health professions, there is not a lot that can go terribly wrong with the patients.  And many optometrists find the business of optometry to be manageable and reasonable.  But most ODs have their least favorite aspects of being in practice.  It is quite fun to talk about the favorite things about being an OD, but let’s do that next time.

Least Favorite #3:  Dealing with the impact of insurance programs.

The impact of insurance programs on the practice of optometry cannot be considered without recognizing that patients go to the eye doctor because of their insurance coverage.  But the overall challenges of managing patient insurance causes a pretty big number of ODs to skip participating in plans or even leave plans after having been participants.  I have resisted participating in some vision and medical plans and recently have found that when local employers add coverage on a plan in which I am not a participant, they still visit our clinic for care when we tell them that we simply cannot join that plan.  We do risk losing product orders to local doctors who are on the panels, but our practice is predicated on delivering top-notch eye care so that doesn’t hurt as much as it would if we were product oriented.

Least Favorite #2:  Firing employees.

If you practice in a setting where you must manage or employ staff, one of the most miserable feelings is that associated with firing an employee.  When I reflect back on the termination of an employee, two things are typically true:  I waited too long to make the decision, and the individual is often relieved.  Your employee relationship can be somewhat parental, where the doctors serve a guiding role to the staff and they define and enforce the rules.  The difference is that there are times when the OD businessperson decides that there is no possible resolution of a staffperson’s skills, attitude, or performance.  My main advice to make firing an employee easy is to make it simple and don’t try to bring up the history of issues.  Use a simple statement:  “This simply is not working, and I think we both know the issues and each of our views of how things are going; but I would like to respectfully ask that you understand that we are going to discontinue our relationship effective now.”

Least Favorite #1:  Misunderstandings of optometry.

My wife knows what I do for patients, so do my kids and my parents and many of my patients who have been paying attention.  But for the most-part, the effort of organized optometry and individual optometrists has not yet moved the pendulum of understanding to really allow for full awareness of what we do.  Insurance companies, vision plans, bad marketing programs, and indifference are all at the root of optometrists not being fully understood for what they do.  We are all proud of our history of vision correction services and products, but we are still annoyed by the question, “don’t I need to see an ophthalmologist for that?”  Thankfully, our practice is wonderfully aligned with many tremendous ophthalmologists who know that we take our referrals seriously and that we will always send patients when the case exceeds our abilities.  Many times though we can do more than the patient believes.

Do you have other least favorite aspects of optometry?  Go ahead, get it out of your system.  Next time, we will discuss the top three.

Regardless of practice mode or location, every optometrist monitors some preferred metrics to evaluate the health of his or her practice.  Just like measuring visual acuities or intraocular pressures, the wellness measures need to be monitored at baseline and then over time for trend analysis.  Businesses big and small have key points that they monitor to guide budgeting, expenditures, and key investments.

Beyond tracking the practice’s income and expenses, today’s optometrist is challenged to know the business inside and out because of the critical decisions that must be made about involvement in managed care programs.  From local HMOs to national vision plans to Medicare and Medicaid, doctors face the never-ending task of trying to decide how low their fees can go in order to participate.

Most optometrists accept some managed care patients; some take many.  Those that are employed by managed care systems have their take-home pay tied to volume of patients, RVU generation, or some other equation that requires attention to detail.  Independently employed doctors have a more challenging analysis and, frankly, don’t have any good tools to help them know the bottom line impact of managed care.

There are consultants who can help by applying their machine to the analysis process.  These advisors truly have the success of the practice at their core.  They have acquired knowledge from experience in the industry and they apply it as specifically as they can after getting to know their clients.  But like every optometrist they serve, they have biases and it is critical that the doctor has a clear view of the path that is desired when contracting with a consultant.

Vendors of equipment, software, and wholesale products also offer advice.  Their biases are even more angled, which is fine as long as the doctor has that understanding.  Ophthalmic companies derive revenue from helping optometrists make revenue, so it is not necessarily a negative to take advice from them.  They only do well if you do well, but you must tread carefully with their advice if it overstates their value to you.

Recent examples of this have arisen in the EHR industry.  In light of the money that will be available in 2011-2016 from the federal stimulus act, some software companies have made the potential maximum dollars available look like a lot more than is really available.  How?  Well, Medicare already pays physicians (and optometrists) a small bonus if they report PQRI codes on a consistent basis.  The theory is that with software, doctors will be more likely to do quality reporting and thus will qualify for the bonus payments.

The rub is that the bonuses are paid on top of Medicare payments for services rendered, currently as a 2% addition.  The maximum PQRI payment for a doctor is $5,000 in a year.  To receive those dollars, you would have to receive Medicare payment of $250,000, and unless your fee schedule is at the rock bottom that Medicare pays, you would probably have billed 50-100% more than that for the service rendered.

That’s not very likely, and thus it’s really a stretch for a software vendor to say that use of EHR will land you that extra $5,000 maximum.  How many doctors know that?  Not many.

For that reason, you have to pay attention to your own practice metrics in order to be sure that you make smart business decisions.  You have allies in the industry to help you, and choose them wisely and listen to what they say carefully.  But validate anything you hear — just like you do when your technician measures IOPs on your glaucoma patients.

In absence of your careful attention, decisions that you make for your practice could be unwise.  Why let the system play you?  Take the pulse of your practice more carefully than ever… today.

I’ll bet that you are where you are today because of mentors who have significantly influenced your life.  And if I take it a bit further, odds are good that you have achieved your status as an optometrist because of an optometry mentor.  It’s likely that there is significant mentoring in other professions and careers, too, but optometry mentors are typically very special people.

I have had my share of optometry mentors.  A couple of optometrists were friends of my dad and they advised me to attend a great little optometry college in the Windy City.  Another OD was the one that gave me the vision correction in middle school that showed me the power of the diopter (or two!)

I had great instructors at optometry school.  I’ve met a lot of ODs in the last twenty years who learned from legends who shaped their careers.   The influence of teachers can push both ways because there are times when a student clinician learns how to be outstanding, but there are others that teach one how to not care for patients.

I had “mentor” experiences in my student career that taught me tremendous lessons about the type of doctor that I did not want to be.  One was an ophthalmologist who would ask elderly glaucoma patients who reported medication non-compliance if they wanted to select the color of their seeing-eye dog before they went blind.  Another was an optometrist for whom I worked in a clinic, who treated his staff as though they were never meeting his standards for patient care.

But more importantly, I have had tremendous mentors that were positive influences.  I consider them all to be important people in my life.  One of my mentors recently lost his life in a battle with cancer that he fought valiantly.  I didn’t know Mike extremely well, but he was the optometrist in the hometown of one of my optometry school buddies and he became an optometry colleague during my career.

In my first experience, he opened his office to us before we took a state board licensing exam.  It was probably not a big deal to him, but to us it felt like we were being treated like princes.  Later, after I had become an optometry volunteer, I learned about how a person can lead without having to gain attention.  He served optometry and his patients well and unassumingly.  And he paid me the ultimate compliment - he referred his best friend to me as a patient.

I had a chance to thank him when he said goodbye to me the last time we were together, but it bears repeating:  Thanks, Mike.  I’ll commit to being like Mike, and I hope you do, too.

Do you have a great story about the outcome of your effort to mentor?  Let us hear it.