Reports of Impact of EHRs on Ophthalmology practices - A Sampling of the Literature

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Reports of Impact of EHRs on Ophthalmology practices - A Sampling of the Literature

Introduction It has been suggested that the EHR adoption rate for ophthalmology lags behind that of other specialties. It has been observed that ophthalmology is a field that has unique requirements that can could make EHR adoption challenging. In 2011 Chiang, M et al et al described these features and proposed that these features be taken into account when developing EHR systems for Ophthalmology. Since then, a number of publications have addressed the impact of EHR adoption on Ophthalmology practices. Several of those articles will be described here:

1) Electronic Health Records and Ophthalmology A Work in Progress, Boland MV

In this editorial the author discusses issues facing ophthalmologists who want to implement an EHR. He points out that studies vary significantly in their findings and that there is little solid information to guide clinicians in choosing systems. This is particularly problematic for those clinicians outside of academic practices, as there is a lack of published evidence about success or failure of EHRs in non-academic environments. He proposes establishing standard metrics to assess the effect of EHRs on practices. He also promotes the use of the online system created by the AAO to evaluate their systems, but points out that the data currently available are inadequate.

2) Adoption of Electronic Health Records and Preparations for Demonstrating Meaningful Use : An American Academy of Ophthalmology Survey, Boland MV, et al

 Study Design: Population-based, cross-sectional survey
 Participants: 492 respondents out of 1500 members solicited 
 Size and type of practice: diverse
 Location: AAO US active membership database EHR product: diverse            
 Main Outcomes Measured: EHR adoption rates, user satisfaction, benefits and barriers, availability of EHR functionality 
 Findings: >80% adoption of computerized billing and management systems. 
               Approximately half of practices had computerized medication and/or image management. 
               1/3 were using computers extensively for clinical documentation
               22% had no plans for EHR implementation within 2 years 
               Practices using EHRs were larger, were more likely to include other specialties, and were less likely to be physician owned.
               58% extremely satisfied or satisfied with practice management system 
               49% extremely satisfied or satisfied with their EHR 
               33% extremely satisfied or satisfied with their image management system
               11% thought productivity was increased 
               31% thought productivity was unchanged 
               31% thought productivity was worse 
               26% were unsure about productivity
               40% reported increased costs 14% reported no change in costs 5% reported a decrease in costs 
               42% were not sure about costs
               55% of practices would recommend their EHR to a colleague
               Practices with an EHR were more positive than those without an EHR about barriers to adoption and about perceived and realized benefits to practice.
               15% reported that all imaging devices were integrated 
               20% reported that most imaging devices were integrated 
               16% reported that some imaging devices were integrated 
               49% reported that few imaging devices were     integrated
               33% reported that images were uploaded directly from devices to image management system (IMS) 
               29% reported that scanned paper documents were transferred to the IMS 
               10% reported that manually transcribed data was transferred to the IMS
              Meaningful Use: 
                 30% reported that EHR was ready for meaningful use 
                 25% had plans to upgrade or install a new system 
                 18% were undecided about how to proceed 
                 18% had no plans to pursue incentive payments
Author discussion points: 
                The EHR adoption rate is more than double the rate from a similar survey in 2007, but less than anticipated by the responses in that previous survey. The adoption of EHRs by ophthalmology practices is similar to     medicine overall. They suggest that findings from EHR adopting practices (larger, multispecialty, not physician owned) may not always apply to practices that are smaller, ophthalmology only, or physician owned. Compared to the previous survey: Satisfaction rate has decreased. The proportion of respondents that would recommend their EHR to a colleague has decreased. Satisfaction among ophthalmologists seems to be less than for medicine in general. The authors discuss possible reasons for the decreasing satisfaction rates and low meaningful use rates.

3) Electronic Health Record Systems in Ophthalmology: Impact on Clinical Documentation, Sanders DS, et al

Study Design: Cases of three different diseases in which the same problems were documented by the same provider on different dates using EHR versus paper methods were selected. They were evaluated using qualitative and quantitative methods. The diseases studied were age-related macular degeneration, glaucoma, and pigmented choroidal lesions. 
Number of cases:150 consecutive pairs of examinations. (50 pairs for each disease) 
Practice type: large U.S. academic medical center EHR product: EpiCare, images managed by a different vendor based system which allows images to be copied and pasted into EHR notes. 
Main Outcomes Measured: 
        Quantitative: Documentation score reflecting the number of examination elements that were recorded. Evaluation of the presence or absence of a set of critical findings Quantity of paper charts containing one or more illegible words. 
        Qualitative: Comparison of 3 cases that were selected to illustrate typical qualitative differences between paper and EHR records. 
      For each disease the documentation score was significantly higher for EHR records than for paper records. 
      For 2 diseases, the number of critical clinical findings recorded was higher. 
      For age-related macular degeneration, critical finding scores were higher with paper notes. 
      Most findings were documented more frequently in EHR notes, though some findings, including critical findings, were documented more frequently in paper notes. 
      No EHR records had illegible notes. 6% of paper notes had illegible words.
      EHR notes were longer than paper notes. in all cases, primarily due to computer generated text. 
      No EHR notes used drawings to represent findings. 
Author discussion points: They discuss potential positive and negative aspects of longer notes. Completeness vs potentially inaccurate information (copy and paste), or burying of critical information in long lists of insignificant findings. Paper notes focused on graphical representation while EHR notes were entirely text based. They suggest reasons why EHR drawing tools are not used much. They discuss potential positive and negative aspects of EHR use.

4) The influence of a specific Ophthalmological electronic health record on ICD-10 coding, Kortum K, et al

Study Design: Observational analysis of a 6 month period prior to and after introduction of an ophthalmologic specific EMR.
 17,493 cases before implementation and 18,538 cases after implementation 
 Study location: Major regional academic ophthalmic department in Germany
 EHR product: ERP 6.0 (Cerner) with customized graphical user interfaces designed by a team of ophthalmologists and computer scientists. 
 Main outcome measures: diversity and number of ICD-10 diagnoses and number of patient consultations. 
     Higher variety of diagnoses (156.2/week prior to implementation and 186.8/week after implementation.	
     Higher number of diagnoses per case and per week after implementation. Increase in documented emergency department cases. 
     No change in scheduled outpatient cases. 
 Author’s discussion points: Suggestion that convenient access to an online catalog with full text search may have contributed to the increase in diagnoses. In paper charts, codes were often entered by administrative staff even on charts with no diagnosis entered. Thus vague “wild card” diagnoses may have been entered frequently. After implementation, codes were entered by physicians. They discuss inadequacies of ICD-10 diagnoses for ophthalmology.

5) eHealth 2015 Special Issue: Impact of Electronic Health Records on the Completeness of Clinical Documentation Generated during Diabetic Retinopathy Consultations, Mitsch C, et al

 Study Design: After conversion to an EHR, paper records from before and electronic records from after the conversion were analyzed and graded for the presence of important medical features in assessment of diabetic retinopathy. The list of important features was derived from the American Academy of Ophthalmology Preferred Practice Pattern for Diabetic Retinopathy. 
 Number of cases: 70 paper cases and 2,351 EHR records. 
 Practice setting: Outpatient clinic for diabetic retinopathy at an academic medical center in Austria	
 EHR system: Customized EHR designed specifically for diabetic retinopathy consults. The EHR was developed in collaboration with CEMSIIS, from a software suite “research data and analysis” that is used throughout the hospital system. The customization was developed with input from ophthalmologists from the diabetic retinopathy department. 
 Main Outcomes Measured: Scores based on presence or absence of items on the list of important features. 
    Documentation scores were significantly higher in the EHR than in the paper records in all categories except visual acuity. 
 Author’s Discussion points: They explain that the discrepancy between number of paper vs EHR records examined was due to the relative ease of analyzing EHR records. They point out that the EHR has a more granular structure which prompts providers to enter information including negative findings. They point out that the absence of a comment about a critical feature (as is often found in paper records) leaves ambiguity. They point out that some ophthalmologists that initially resisted the introduction of the EHR have since “unreservedly acknowledged the system’s advantages”.

6) A Two Year Longitudinal Assessment of Ophthalmologists’ Perceptions after Implementing an Electronic Health Record System, Erlich JR, et al

 Study Design: Longitudinal survey of faculty ophthalmologists conducted before and at several time points after a new EHR implementation. 
 Number of subjects: 46% - 71% of 56-62 faculty members. 
 Practice Setting: Large academic ophthalmology practice in the US.
  EHR product: EpicCare ambulatory
  Main Outcomes Measured: Physician satisfaction, productivity, documentation, and workflow 
    No significant change in the amount of time entering data into charts on workday evenings/nights, on non-clinical administrative days, or on days off. 
    No reported significant change in efficiency and workflow. 
    No significant change in perceptions of patient safety 
    There was a significant decrease over time in the percentage of respondents who reported that the system allowed them to create high quality documentation (90.6% pre-implementation, and 37.9% - 55% post implementation). 
    There was a progressive decrease in the respondents who felt the system supported meaningful interaction with patients. (98.6% pre implementation, 12.8% at 24 months post implementation). 
    There was an increase in the number of respondents who felt the “health record system” had a negative impact on job satisfaction (15.6% pre-implementation, 59% post implementation). 
    No statistically significant change in job satisfaction. 
 Author’s discussion points: They state that their EHR experience is similar to that of other specialties at the same institution. They point out that this study looks at attitudes over time, which is not done in many other studies.


Chiang MF, Boland MV, Brewer A, Epley KD, Horton MB, Lim MC, McCannel CA, Patel SJ, Silverstone DE, Wedemeyer L, Lum F; American Academy of Ophthalmology Medical Information Technology Committee. Special requirements for electronic health record systems in ophthalmology. Ophthalmology. 2011 Aug;118(8):1681-7. doi: 10.1016/j.ophtha.2011.04.015. Epub 2011 Jun 16. PubMed PMID: 21680023. Cited in PMCRelated citations

Boland MV. Electronic Health Records and Ophthalmology: A Work in Progress. JAMA Ophthalmol. 2015 Jun;133(6):633-4. doi: 10.1001/jamaophthalmol.2015.0913. PubMed PMID: 25879887. 
 Boland MV, Chiang MF, Lim MC, Wedemeyer L, Epley KD, McCannel CA, Silverstone DE, Lum F; American Academy of Ophthalmology Medical Information Technology Committee. Adoption of electronic health records and preparations for demonstrating meaningful use: an American Academy of Ophthalmology survey. Ophthalmology. 2013 Aug;120(8):1702-10. doi: 10.1016/j.ophtha.2013.04.029. Epub 2013 Jun 24. PubMed PMID: 23806425. Cited in PMCRelated citations

Sanders DS, Lattin DJ, Read-Brown S, Tu DC, Wilson DJ, Hwang TS, Morrison JC, Yackel TR, Chiang MF. Electronic health record systems in ophthalmology: impact on clinical documentation. Ophthalmology. 2013 Sep;120(9):1745-55. doi: 10.1016/j.ophtha.2013.02.017. Epub 2013 May 16. PubMed PMID: 23683945. Cited in PMCRelated citations

Kortüm K, Hirneiß C, Müller M, Babenko A, Kampik A, Kreutzer TC. The influence of a specific ophthalmological electronic health record on ICD-10 coding. BMC Med Inform Decis Mak. 2016 Jul 26;16:100. doi: 10.1186/s12911-016-0340-1. PubMed PMID: 27460682; PubMed Central PMCID: PMC4962360. Free full textRelated citations

Mitsch C, Huber P, Kriechbaum K, Scholda C, Duftschmid G, Wrba T, Schmidt-Erfurth U. eHealth 2015 Special Issue: Impact of Electronic Health Records on the Completeness of Clinical Documentation Generated during Diabetic Retinopathy Consultations. Appl Clin Inform. 2015 Jul 29;6(3):478-87. doi: 10.4338/ACI-2014-11-RA-0104. eCollection 2015. PubMed PMID: 26448793; PubMed Central PMCID: PMC4586337. Free full textRelated citations

Ehrlich JR, Michelotti M, Blachley TS, Zheng K, Couper MP, Greenberg GM, Kileny S, Branford GL, Hanauer DA, Weizer JS. A Two-Year Longitudinal Assessment of Ophthalmologists' Perceptions after Implementing an Electronic Health Record System. Appl Clin Inform. 2016 Oct 12;7(4):930-945. PubMed PMID: 27730248. Related citations 

Submitted by Jessica Wolin MD

A few comments from the author of this post:

There are some things that stand out as these reports are examined side by side. First: The systems that were designed with input from the ophthalmologists were generally well liked, whereas those that were adopted from a system wide EHR tended to be disliked. Second: The biggest issue with EHR systems in ophthalmology seems to be the ability to include diagrams in the notes. Replacing diagrams with narrative seems to be unpopular even though the narrative has more complete information. It is not clear whether this is a question of habit, or whether the narrative information is less useful even if it more complete. It seems that if pictures could easily replace the diagrams, the question of narrative vs. diagram would have a different significance. Third: These reports are of particular interest given that surgical specialists and small practices lag behind others in voluntary use of EHRs.

Submitted by Jessica Wolin MD