 Kelly E. Chung, MD 

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Practices can get more out of their EHR system than billing and documentation. Systems can be customized to provide many forms of clinical-decision support including alerts and medical evidence relevant to ophthalmology practices.

 (EHR) systems in improving the quality and safety of care may be undervalued in practices that have not customized the generic alerts and forms in their EHR system to make them more relevant to the needs of ophthalmology patients, according to Kelly D. Chung, MD.

Many physicians may have become jaded about EHR alerts-also known as clinical-decision support-since a flagged drug-drug interaction may have no relevance to the medications commonly used in their particular specialty, resulting in a high frequency of false positives, said Dr. Chung, who is in private practice with Oregon Eye Specialists, Portland, and a member of the American Academy of Ophthalmology Medical Information Technology Committee.

However, both medication alerts and other support functions of EHRs can be modified to make them more pertinent, she said. “If you can implement some focused support tools for your practice, it can help you move beyond just using your EHR for documentation and billing to using it for improving the quality of your patient care,” she explained.

“Clinical-decision support is the use of computer functionality to make us better doctors by selectively presenting information when we need it,” Dr. Chung said. “And when we need it is the key point-the last thing we need to do is click on more information that isn’t relevant; a lot of the things that have been built into these big systems are pretty generic but can be modified to be more relevant to a specific practice setting and specialty.”

Types of alerts-some of which can be customized without special assistance from your vendor and some that might require coding- include immediate alerts, such as warnings and critiques; event-driven alerts and reminders; order sets, care plans, and protocols; parameter guidance; smart document forms; relevant data summaries; predictive and retrospective analytics; filtered reference and information; and the expert work-up advisor.

“Studies in the realm of clinical-decision support have demonstrated their ability to improve the quality and safety of our care,” Dr. Chung said. As a case in point, a study on the effectiveness of documentation forms and decision support tools for hydroxychloroquine screening showed a definite improvement in the appropriateness of screening (from 46% to 75%) and a decrease in inappropriate screening from 25% to 2% (Ophthalmology. November 2016).

Instances of clinical-decision support specific for ophthalmology medical alerts include:

A graph shows that a glaucoma patient’s IOP is above the target pressure.

Clicking an advisory icon for ethambutol, a rarely encountered drug, shows the recommend screening for ocular toxicity.

The system highlights that a patient is taking certain systemic medications such as beta-blockers or alpha adrenergic agonists (e.g., Flomax).

Systemic medications that have ocular side effects can be highlighted or flagged, and clicking the drug name for further information reveals what those are. For example, docataxel (Taxotere) could cause a host of ocular side effects.

An intake form for patients on hydroxychloroquine will prompt the user to record relevant information including height, weight, and medication history. Further, the latest dosage guidelines can be incorporated into a standard letter to be sent to the referring rheumatologist to help disseminate preferred practice guidelines.

Cataract surgery planning checklist: Medicare carriers require the notation before surgery that a small pupil might need special intraoperative management or that a cataract might need a capsular stain for billing a complex surgery code. A history of recent contact lens use or refractive surgery might be missed, resulting in erroneous intraocular lens power selection, and these items should be checked for systematically like a pilot going through a preflight checklist. The EHR can customized to provide these types of tools for any subspecialty or type of procedure.

Reminders/ticklers: if a diagnostic test such as a sedimentation rate to check for giant cell arteritis or a carotid duplex study or neuroimaging is ordered outside of the office, a “timer” or tickler to remind the user to check on the result if it doesn’t get “pushed” to you.

“We are far from using the power that these systems could give us to enhance rather than just document care,” Dr. Chung said. “EHR companies have been so focused on other priorities that making clinical-decision support enhancements has taken a back seat to regulatory considerations,” she said. “Make your clinical-decision support work. Customize it to your needs, and implement best medical evidence into clinical workflows.”

Dr. Chung’s suggestion for practices: If you aren’t aware of all the decision-support capabilities of your system or need help with modifications, speak with your vendor and appoint a physician or technician champion in your office to lead this process from within your organization
 


P: 503/292-0848 E: kchung@oregoneyes.net


This article was adapted from Dr. Chung’s presentation at the 2017 meeting of the American Academy of Ophthalmology. She has no relevant financial disclosures. Clinical-decision support includes ticklers, medical evidence relevant to ophthalmic practices.

Kelly E. Chung, MD

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