Look for EMRs With Many Detailed Touches, Good User Interfaces, And Adaptability to Special Circumstances
For some optometrists, myself included, the apex of the doctor-patient engagement lies in specialty contact lens prescribing. These specialty lenses can include scleral contact lenses, bitoric corneal gas permeable lenses, hybrid lens designs, and overnight corneal reshaping. Whereas disposable contact lenses are seemingly on the verge of deregulation and self-verification in the U.S., prescribing specialty contacts requires expertise, experience, and careful listening to the patient’s needs. Specialty contact lenses can both open new avenues to clear vision not previously possible and provide substantial support to a business’ financial wellbeing while also representing a bastion against commodification. Finally, specialty contact lenses bring compelling personal satisfaction: the specialty contact lens patient is more apt to recognize that it was the doctor—and not the brand of contact lenses—which brought about the desirable outcome.
The Importance of Electronic Medical Records for Specialty Contact Lens Prescribing
Nothing can sour the joy of the process of prescribing specialty contact lenses than a poorly matched electronic medical record (EMR) system. I have used five different EMRs over the course of my career and have experienced firsthand the devastating effects of an inefficient EMR that does not properly pattern the workflow required for specialty contact lenses. A poor EMR interface can redirect the practitioner’s attention away from the patient, increase the risk of errors and decrease patient satisfaction.
A good EMR, on the other hand, can free up the doctor’s time so that more of it can go toward educating the patient and addressing their questions and concerns. A good EMR also reduces the risk of order errors and improves service efficiency.
It is important, however, to realize that there is no “perfect” EMR. None are as easy to use as an iPhone and they all have constraints that require workarounds. While frustrating, this is also understandable: big tech has more resources for software development and testing than EMRs, which serve a much smaller number of users.
EMRs for Specialty Contact Lenses: What to Look For
There are several must-haves for your EMR when it comes to specialty contact lenses; these are detailed in the sections that follow. The features you want include:
- The flexibility to fully describe lens parameters in a systematic fashion.
- The ability to document consultative and order information.
- The ability to silo administrative information from patient disclosure.
- Clear organization of lens use by eye and date, and if the lens is dispensed or returned.
- An intuitive interface which patterns workflow and standardizes the organization of data.
Entry Fields to Specify and Collect Data Important for Specialty Contact Lens Prescribing
Unlike disposable contact lenses, specialty contact lenses have specifications that go beyond base curve, power, and diameter. It is common with custom lenses to specify material, color, diameter, and design-specific parameters. For example, with corneal refractive therapy, there is return zone depth (RZD) and landing zone angle (LZA). With scleral contact lenses, there are specifications for each scleral lens design corresponding to sagittal depth, limbal clearance, and scleral landing zones. Often, the names of these specifications vary according to the proprietary lens design. There may also be specifications for toric scleral landing zones, peripheral recesses, the addition of Tangible HydraPEG, a drill dot, or increased center thickness for flexure control. For simultaneous vision multifocals, there are specifications of the near add diameter and power, and in some cases asphericity and decentration. For prosthetic lenses, there is color and pattern of print, including a translucent or black-backing, pupil size, iris diameter, and selection of a clear or black pupil. Often, these specifications are calculated or determined in conjunction with a manufacturer’s consultant. Hence, the practitioner must be able to indicate these in the EMR rather than the administrative practice-management side of the software.
With some EMRs, it may be possible to re-purpose entry fields intended for traditional specifications for certain specialty lens specifications while still passing software validation. For example, while you may not find an entry field for sagittal depth, you may be able to put this value in a field intended for a secondary peripheral curve width without the software complaining that there are too many digits. The downside to this strategy is that the practitioner may not remember which entry field is used for each specialty lens specification and therefore lose recording consistency. This can confuse the practitioner in the future and others who review the records.
It is important that your EMR has a catch-all field where you can enter specialty contact lens parameters by free typing. Even in cases where you enter specialty lens specifications in some of the existing entry fields intended for disposable contact lenses, there is usually information that does not lend itself to documentation in that way. Information documented in this “overflow” field should transfer to your staff for ordering and show up on a prescription print-out.
Your EMR should also have a separate entry field for internal administrative notes such as cost and warranty exchange periods. These generally are not necessary nor suitable to indicate on printed exam records, receipts, or prescriptions. This field is also an appropriate place to document information which, if disclosed to the patient, could undermine their wellbeing and successful treatment.
EMR Organization: Detail Matters
In custom contact lens prescribing, organization is key. The EMR must allow designation of a contact lens as “presenting,” “diagnostic,” or “final,” with the ability to further specify “Presenting 1 of 3,” “Presenting 2 of 3,” and so forth. In the specialty realm, you need the ability to document, for example, that a patient is wearing a scleral lens in the right eye and a corneal GP lens in the left eye that is worn over a soft disposable piggyback lens. There also needs to be flexibility to indicate if a patient is wearing an unknown lens in a particular eye, for example, if the patient believes the right and left lenses are switched, or if the patient resorted to wearing a lens from two years ago after losing the more recent pair. When on-eye diagnostic contact lens evaluation is performed, every lens that is evaluated on the eye must be neatly documented and associated with the appropriate vision and slit lamp findings or else run the risk that the incorrect lens is ordered.
The EMR must allow facility and interchangeability in copying the parameters of a presenting lens to a diagnostic lens, and then to a final contact lens. For example, if the patient’s presenting contact lens is the same as last year’s final contact lens prescription, the practitioner needs the ability to copy forward last year’s final Rx and note that it is today’s presenting Rx. If a -2.00 DS over-refraction is found, then today’s presenting Rx gets copied into a new Rx and the practitioner can modify the lens power to account for the -2.00 over-refraction.
Because specialty contact lens prescribing is iterative, information about whether a particular final Rx was ordered, dispensed, or returned is of utmost importance. The first set of custom scleral lenses dispensed often requires a subsequent exchange to refine physical specifications of the lens or the refractive behavior of the lens. You need to know the order date so that you and your staff can quickly identify when the warranty exchange period expires and advise the patient accordingly. You need also to know when a lens was dispensed, if at all, and if a specific lens was returned so that credit can be claimed. Sometimes, when a lens is exchanged for a newer lens, the patient returns and wants to revert back to wearing the previous lens; an EMR needs to be able to respond to this scenario. This is important when the patient returns in a year and needs duplicate lenses.
Due to the potential number of returns and exchanges during the prescribing process, a poor inventory tracking system can result in unnecessary and costly mistakes. For example, there may be orders that fall outside the warranted exchange period, remakes with parameter changes attributed to the wrong set of lenses or returned lenses that never get processed by staff for manufacturer credit.
Data Layout and Ease and Accuracy of Documentation
A good EMR has an intuitive user interface, with necessary information for contact lens prescribing placed on a single page so that the practitioner does not have to flip back and forth through different pages. For example, eye dominance, refraction, and keratometry should coexist in the same screen for initial diagnostic lens selection.
When honing down to a short list of proposed EMRs for your practice, assess the burden of documenting clinical findings and creating a prescription using the various EMRs for the same patient. One useful metric is counting the number of mouse clicks to document the same thing. My most-hated EMR required approximately three times as many mouse clicks to enter the same data as my current EMR. It is not only mouse clicks, though: scrolling and keystrokes can cumulatively wear on your patience and divert your attention, which should be allocated to being present with the patient in your exam room.
Your EMR should be sophisticated enough to intuitively format entered data, something analogous to auto-correct or the auto-suggest used in Google web searches. For example, if you enter in -2 into the entry field for sphere power and the cylinder and axis fields are left empty, the EMR should reformat the entry so that it displays the entry as -2.00 DS. Otherwise, there is inconsistency: data could be entered and saved as either -2, -2.00, -2.00 Sph, or -2.00 DS. The best user interfaces will also allow multiple methods of data entry, accepting not only what you type with a keyboard but affording the ability to enter data using the mouse. Ultimately, the displayed format should be consistent regardless of how it was entered.
Your EMR is Important: Proper Due Diligence Will Pay Off
As the technological backbone of your practice, careful selection of your EMR is one of your most important decisions. Implementation of an EMR requires considerable time and resources to set up, convert data, and train staff—meaning switching will not be easy. Using a poorly matched EMR is a punishing experience that feels worse with every patient that you see. And with more than 30 EMRs in the eye care field, selecting one is not easy. Looking for a shortcut? Talk to eye care practitioners you trust, who may be able to provide you more valuable feedback than any software vendor sales rep. At some level, moving to a new EMR is a leap of faith, as there is some degree of uncertainty in how it will work for your practice. Still, EMR selection is a high-stakes decision which requires your careful consideration.