Digital technology in plastic surgery

Certification

Determining whether the chosen EHR is certified by the ONC (Office of the National Coordinator of Health Information Technology) has traditionally been important, especially for plastic surgeons and other physicians participating in certain government incentive programs. Certification is meant to assure that the EHR system offers the capability, functionality, and security to meet the Meaningful Use (MU) criteria established by the Centers for Medicare and Medicaid Services (CMS). The Meaningful Use program underwent three “stages” of implementation along an 11-year timeline (culminating in the final Medicaid incentive payments being slated for 2021), with penalties levied against practices that see significant Medicare or Medicaid volume but fail to demonstrate compliance with MU. Certification provides one level of reassurance that the EHR system both allows entry of data necessary to achieve MU compliance and a toolkit for submission of reports to CMS for validation and incentive processing. For plastic surgeons who did not participate in the Meaningful Use program, certification may still provide some level of assurance that the program meets certain standards of functionality, security, and interoperability, and probably is more likely to survive consolidation than other non-certified programs.

Server on-site or off-site or subscription model (SaaS – Software as a Service)

There are three principal models through which an EHR program can be provided to users. Some EHR vendors can be deployed all three ways. The most traditional model of software delivery houses the program and data on a server in the office owned by the physician/group. The physician has complete control of the data, but is responsible for hardware maintenance, back-ups, insurance, and security, as well as manual updating of the software. Access from a remote location or satellite offices is also maintained by the physician’s practice, and may involve high-speed data access lines (T1 or fiberoptic cable, for example), Virtual Private Networks (VPNs), and other remote logging programs. This model may require higher upfront costs for hardware infrastructure and depending on the size of the practice, one or more IT specialists outsourced or employed in-house. Another model involves using a server that is housed off-site, maintained by a third-party vendor. The physician/group still maintains complete control of the data but leases space in a remote server. Updates frequently still require manual effort, but responsibility for servers, back-ups, and insurance is assumed by a third-party vendor.

Finally, the Software as a Service (SaaS) model is a subscription service in which the program and data are maintained and updated by the EHR vendor, with the software accessed via the computers/devices in the practice – much like the way Gmail, Yahoo! Mail, Dropbox, and other online programs work. The updates are usually real-time and performed automatically by the EHR company, often without disrupting the software’s availability. The server function, back-ups, and security of the server is assumed by the EHR company. Depending on the contract, the physician/group may incur fees to have the data extracted into a usable format when changing vendors. Some contracts and user licenses permit the EHR company access to or ownership of the data. In some cases, de-identified data (records that have been stripped of identifying personal or demographic information) can be used by the vendor for purposes of research, product development, or aggregation and commercialization. This model usually boasts lower upfront costs for hardware purchase and installation, and delivery through a cloud infrastructure facilitates easier access from remote locations and satellite offices. Increasingly, both professional and consumer software is being delivered through the SaaS model, with support, training and updates bundled into the subscription costs, and availability provided “anywhere, anytime and on any device”. These models also facilitate interconnection with other cloud-based services and third-party product integrations, including payment processors, photo/image management systems, patient engagement tools, and marketing platforms.

Stability in the market

A search of the ONC-approved comprehensive EHR list as of 2021 shows 812 approved programs, a number that is probably unsustainable. Even in 2012, 75% of users of EHR products were concentrated among the top 6 vendors serving hospitals and the top 15 serving outpatient venues. Accordingly, an important consideration when choosing an EHR system is whether the product is anticipated to survive the inevitable consolidation of the market among sustainable leading vendors. Such vendors often have the advantages of consistent revenue from the installed user base along with scalable physical and human resources that may allow them to fulfill further governmental or other regulations better and to make updates and improvements to their programs. On the other hand, larger EHR companies may be somewhat less responsive to suggestions by users to improve the usability or functionality of their programs or to add features that are crucial to only a small subset of their users. As plastic surgery is a relatively small specialty, this can sometimes be an issue impeding the timely selection of an EHR with essential features needed by the average plastic surgeon. Efforts at consolidation and platform development in the EHR market for plastic surgery and aesthetic medicine has been driven by institutional investment by private equity and venture funds, with some vendors acquiring smaller but high-performing EHR/practice management systems and other modules for specific specialties, to gain market share and bolster long-term market sustainability.

Features and functionality

Most certified EHRs can adequately accomplish the generation of a satisfactory progress note, problem list, medication list, etc. More important is the ease of use of the software. The usability of many programs is hampered by the requirement for multiple clicks, non-intuitive navigation, and a cumbersome maze of windows and menus. It is critical to request a detailed demo of the functioning program and to engage with current users of the system who are reference clients of the vendor. One way to accurately experience the ease (or difficulty) of use and functionality is to have the demo performed in a manner that follows the practice’s current workflow from initial patient contact, scheduling, registration, intake, note generation, billing, reporting, follow-up, etc.

As discussed above, many EHRs in the market were not designed with plastic surgeons in mind. Practices should carefully vet those features that may not be accessed by other physicians, including cosmetic quote generation, inventory, and point of sale management of product lines, prepayment for services (e.g., deposits and prepayment for cosmetic surgery or package pricing for lasers, etc.), photo archiving with rich search and display features (see below), patient management (see section below), and others. Contracts and user agreements that are contingent on the development or enhancement of a feature or functionality should have clearly agreed-upon language in the contract with timelines and benchmarks, along with consequences for missed milestones.

Support and implementation

Implementation, training, and support are critical services provided by vendors. Important considerations include the length, complexity, cost, and responsibilities for the installation process as well as the amount of initial and ongoing training included and available. Guaranteed limits on outages and unavailability of the software during updates, bug fixes and other interruptions should be sought and practices should seek clear terms regarding the support resources available in such instances, especially after normal business hours. Even something as seemingly trivial as the time zone of the vendor’s support headquarters may have an impact on office productivity if the practice experiences bugs, slow data processing, access problems or other issues during normal business hours in another time zone. Many vendors provide extended hours or offer “premium” support (typically at a surcharge) to cover such contingencies. Most experts recommend that busy practices anticipate a decrease of 50% in both productivity of office staff as well as physician volume during the implementation period of the EHR (which in some cases can last months to a year or more). One study estimated an average of 611 hours required to prepare for implementation of the EHR, and 134 hours needed by end-users (physicians, clinical, and non-clinical staff, etc.) to become sufficiently familiar with the EHR system to feel comfortable using it regularly with patients. Some vendors offer significant self-study training and onboarding tools while others require more direct customer support during the implementation phase.

Contracting considerations

As with most contracts, it is advisable to have an attorney familiar with such transactions review the EHR vendor’s contract, including (where appropriate and provided) Master Services Agreements, Statements of Work, and User Agreements/Terms of Use. Some specialty societies and state medical societies also offer resources on this topic. Some basic considerations to delineate include:

• 1.

  Who owns the data?

• 2.

  Does the contract grant the EHR company permission to access the physician’s patient data and if so, is it in a de-identified and aggregate form and is the company permitted to sell the data to other parties?

• 3.

  Is there a required duration of contract? If so, what constitutes a breach of contract to allow the physician to terminate the agreement early (e.g., excessive downtime, lack or loss of certification by ONC, failure to create agreed-upon features, etc.)

• 4.

  When the physician changes vendors, what is the process to decrypt the data and provide it into a usable format such that it can be used in another EHR system? What is the cost of the data conversion and agreed-upon timeline and redress for failure to deliver the data in a timely fashion?

• 5.

  What is the process to gain support for downtime of the program – there should be a maximum percentage set for downtime and a maximum time for resolution.

• 6.

  Is there an agreement to work with other vendors to allow for interfacing or integration of different programs (e.g., photo archiving or morphing programs, patient management systems, third-party billing clearinghouses, etc.).

• 7.

  Are there additional costs to add physicians, support staff or satellite offices? Some EHR systems charge per user, others per physician (or provider, including nurse practitioners and physician’s assistants), still others charge per computer terminal workstation license.

• 8.

  Who is responsible for installing and ensuring the functionality of the EHR program?

• 9.

  What capabilities exist for interoperability of systems – i.e., does it link to laboratory vendor data, radiology systems (PACS or DICOM viewers), other EHRs, etc., and is there an implementation or maintenance cost for these services? Is there an open Application Programming Interface (API) to facilitate communication between the system and other products used or anticipated?

Intake and entry of information via patient portals and onsite

ONC-certified EHRs are required to furnish a patient portal that allows patients to access limited portions of their medical record and results as well as interact with the office. Patient portals that allow the patient to enter in demographic and clinical information prior to the office visit can improve office efficiency by minimizing the amount of data entry at the time of the visit. Some programs allow different questionnaires and intake documents to be created which can be tailored to specific physicians’ practice preferences, or keyed to the patient category (e.g., the surgeon is likely to be interested in different information when seeing a hand surgery patient vs. a facelift patient). Demographic entry by patients permits them to update contact information and privacy permissions in a more timely and well-documented manner. Alternatively, such intake forms can be completed in the office with staff members assisting the patient with the appropriate electronic forms or performing a transcribing function for patients who have difficulty working with digital devices. Bubble forms (similar to Scantron standardized test forms but printed by the practice on regular paper) can be created and used in some EHRs which scan the responses into digital format directly into a progress note. Advances in optical character recognition (OCR) and natural language processing (NLP) are likely to further enhance the intake of medical information into structured medical records. Changes to the patient’s medical history that are entered by the patient via online portals may require verification by the office staff for accuracy before replacing or amending prior information.

Data entry at the time of the patient consultation

Copious entry of free text at the time of the patient consultation is neither feasible nor desired. Typically, EHRs make use of a library of templates created for various patient encounters, e.g., initial breast reconstruction consultation, breast augmentation consultation, tissue expander visit, encounter for injectables, etc. Most EHRs permit the templates to include not only the current chief complaint(s) and history of present illness with associated relevant physical exam, but also the typical discussion, treatment plan options, orders, and medical coding. These work best when there are visit categories which are more frequent for the practice, and some EHRs will build these templates at the time of implementation based on the practice’s current EHR documents or paper forms being used in the practice. Certain visits might best be recorded with a visual form or on anatomic images, with annotations typed or drawn as appropriate, as is commonly done when recording injection sites for botulinum toxin and filler treatments. It is important to assess whether the EHR allows the physician or other user to create custom templates to fit the practice’s regular workflows or the user’s personal preferences, as opposed to requiring that requested changes or templates be submitted to the EHR company. Customization can be key to effective use of an EHR system.

With less common or complicated encounters, templates may be less helpful as real-time text editing becomes necessary. Some physicians find it helpful to enter prelim summary notations to be further clarified after the patient encounter, with the note being text-edited at a later date or the provider utilizing speech-to-text transcription in a program like Dragon Medical. Some surgeons prefer to utilize medical scribes who can enter all the appropriate information at the time of the encounter, recording observations rapidly into the EHR while the physician focuses on direct patient care and face-to-face interaction. The scribes can be the physician’s employees physically present in the examination room, or may be at a remote location. One vendor offers HIPAA-compliant scribing services via Google Glass technology, allowing the scribe to see and hear the patient encounter while transcribing from a remote location ( Fig. 35.2 ). Newer EHR products are leveraging the widespread availability of mobile technologies and Wi-Fi to facilitate less disruptive ways to use an EHR in the patient encounter ( Fig. 35.3 ). Still more advanced technologies provide in-room “listening” systems that take conversational speech and convert it to structured notes with data extraction. These are premised on medical data dictionaries and ontologies that allow contextualization of non-technical speech into clinical vocabulary, leveraging artificial intelligence and machine learning tools.