The docs at Capital Eye Consultants have now been live on our EMR system since June.  Our goal is to reach the 90 days of meaningful use required by CMS and therefore receive our first year payment of 18K per doctor.  You may recall that we picked an EMR system that handles both practice management and electronic records.  These systems are used by multisite offices and hospitals as they are designed for multiple medical specialties.  The large EMR companies are also expected to be around in years to come to service their product.  However, there is also an inherent downside to large EMR systems.  First, they are not designed specifically for your specialty.  Therefore, the purchaser ends up designing templates that fit the specialty and mode of the practice.  That ends up being very time-consuming.  Additionally, we have found that the system requires too many key strokes, windows and mouse clicks which detract from the patient encounter.  We are much less efficient than we were using paper.  We have not even begun to import results from ancillary testing equipment such as visual fields, GDx, photos, IOLMaster or OCT.  I can't begin to imagine the number of screen changes and clicks and strokes involved in reviewing those tests or trying to flip back and compare them to previous tests.  Also, the cost is daunting.  The initial program is but the start.  There will be unforeseen training costs, hardware costs and IT costs that we now predict will exceed significantly the reimbursement schedule over 4 years that is provided for by CMS.    Finally, if you assume that because your EMR coded a visit higher than you would have done without it, please be aware there are already articles being written questioning whether the rote documentation of data by EMR systems will be questioned like the old 'WNL' of a paper chart.  EMR documentation doesn't make you bullet proof on audits!

  My advice to anyone considering EMR is to do so only for the right reasons-because you believe it will improve patient care and your efficiency.  Given the uncertain future of heath care in the U.S. and how providers will be reimbursed, the carrot of CMS reimbursements over 4 years vs. the stick of cuts in the percentage of Medicare should not drive your decision on EMR. 

  We have made our bed and we are determined to sleep in it.  We are going for qualifying this year, but then plan to step back and re-evaluate whether to drop out of the program.  This would involve a huge financial loss but at least we can go back to concentrating on patient care and not computer strokes.  There will also be some disadvantages to dropping out such as staying late for dictation as opposed to the rather choppy letters that are created in our EMR system.    Hopefully, for those of you reading this, the more personalized letters would be a welcome return to business-as-usual.  We will keep you posted!

  Multiple good randomized controlled prospective studies over the past 5 years have confirmed the beneficial effect that cataract removal with intraocular lens (IOL) surgery has on the lowering of intraocular pressure (IOP).  Although the exact mechanism for the lowering is unclear, it appears to be long lasting .  This is good news for ocular hypertensive (OHT)/open angle glaucoma (OAG) patients as the cataract removal will lower the IOP which tends to increase with age in this subpopulation.  Immediately after cataract surgery, IOP control in the OHT/OAG patient can be a challenge as these patients can have IOP spikes due to inherent outflow problems clearing of residual viscoelastic and small residual lens particles.  However, most of these short-term IOP spikes can be controlled with oral diamox and strong alpha agonists such as 1% Iopidine.

  Patients going into cataract surgery who are on a prostaglandin analogue such as Xalatan, Lumigan or Travatan Z, should have these drops stopped 3-7 days before cataract surgery to help prevent postop cystoid macular edema (CME).   We are currently recommending patients on these drops (who have open angles) have Selective Laser Trabeculoplasty (SLT) performed after they have been evaluated and are determined to be going forward with cataract surgery.  The SLT is performed and 4-6 weeks later the prostaglandin analogue is discontinued.  The SLT is performed before the cataract removal occurs as it is more efficacious in the phakic (natural lens still intact) vs.the aphakic eye.  The logic and rationale is the SLT will replace the IOP lowering that was provided with the prostaglandin analogue (they work through the same mechanism ) and the prostaglandin drop is not around to cause CME. The further lowering of IOP with the cataract removal will also work with the SLT to prevent the need hopefully to add back the drop.  The above regimen has worked well for our patients; getting them off an extra drop with its associated cost and compliance issues has been a move in the right direction.

  We are all familiar with intra-ocular lens (IOL) use in our cataract patients.  However, did you realize that IOL use for refractive purposes is one of the fastest growing segments in the refractive surgery field??    Both phakic IOLs (additive IOLs) and pseudophakic IOLs (IOLs used after the crystalline lens is removed) are being used at CEC in greater numbers as presbyopic pts and less than ideal LASIK/PRK patients seek this technology\

  The Implantable Collamer Lens ((ICL) has provided incredible visual outcomes in patients that are not LASIK/PRK candidates.  Candidates for the ICL are high myopes, those with unusual topography, and patients desiring a potentially reversible procedure.  The procedure is not FDA approved at this time for astigmatism correction nor treatment of hyperopia.,only -3 to -15 D of myopia  Most of the patients treated with this technology at CEC have 20/15 or 20/20 uncorrected vision postop which is truly amazing since these patients are often 10-15D myopes before their life changing surgery.  The procedure is done at the Fairfax Surgical Center (where all the CEC cataract surgery is performed) and takes about 15 minutes to perform under topical drops and IV sedation like a cataract procedure.  Surgery is performed  unilaterally, with the second eye surgery usually several weeks later.  We see the patient in the office several hrs after the procedure to check the IOP and it is amazing that most patients are already seeing in the 20/40-20/50 range without correction.  At 24 hours, most pts are 20/20-20/30 sc.   Although the FDA has approved the ICL up to the age of 45, Dr. Baldinger had treated many patients off-label into their 50s.  If a patient develops a cataract postoperative after the ICL is placed (about a 1% chance), the lens can easily be removed because of its wafer thin thickness and the fact that the lens doesn't really become fibrosed in the ciliary sulcus where it resides. A newer premium type of IOL can be replaced when the cataract is removed should the patient desire that  technology. In other words, if a cataract were to develop years after the ICL is implanted, the patient would still be capable of taking advantage of future more advanced IOL technology.  Unfortunately, this is not the case when a patient has cataract surgery after LASIK/PRK and there are issues with accurately predicting proper IOL power and issues with higher order aberrations induced from the excimer laser.

  Refractive Lens Extraction (RLE) has also been performed on increasing numbers of patients at CEC.  The ideal patient for an IOL after natural lens removal is a moderate or higher hyperopic presbyope (>2.5D hyperopia).  These pts don't end up with predictable, stable outcomes after LASIK/PRK and will not need to deal with cataract removal down the line as their natural crystalline lens has been removed.  IOL options for these patients are the same as our cataract patients; aspheric monofocal, aspheric toric monofocal and aspheric multifocal  IOLs.  As is the case with all intraocular procedures, one eye is performed at a time.  We do not perform RLE in myopic males because of the higher risk of subsequent retinal detachment in this sub-population.  However, interestingly, highly myopic females do not have a higher rate of retinal detachment and are acceptable candidates for RLE.

 We continue to actively comanage the above refractive lens patients with our referring optometrists postoperatively .   Optometrists are compensated for their time comanging these patients.  Should you have any questions regarding  these procedures or patient candidacy for any of these procedures feel free to speak with Dr. John Baldinger MD, our anterior segment surgeon.

  The new Capital Eye Consultants (CEC) website will soon be up and running (www.ceceyes.com)  The website has been re-designed with you, the referring doctor, and the patient in mind.   On the homepage "Physician Resources" section you will find a "classified ad and professional activity" section where ODs can advertise to sell equipment, look for employees, explore business opportunities, etc.  There is a section to download forms, brochures and view present newsletter for ODs, along with a newsletter archive that also be accessed from the homepage.  Similiarly, the "Patient Resources" area on the homepage will contain a plethora of information to help direct the patient to the resources they may need.  We also have integrated Eyemaginations video players into "Our Services" we render.  These short, but informative videos provide exceptionally high quality animations covering a number of ophthalmic topics.  Directing your patients to our site to view these animations will help reinforce their understanding of many ophthalmic conditions.  Feel  free to link your practice webpage to our webpage, as we anticipate a lot of traffic on the new site.  Look for a press release from CEC when the site is complete (upcoming weeks)