Rethinking the EHR system: The most important components

Documenting practice flow and needs is a critical step in preparation for choosing or replacing an electronic health record system.

Take-home message: Documenting practice flow and needs is a critical step in preparation for choosing or replacing an electronic health record system.


By Lynda Charters; Reviewed by Michael V. Boland, MD, PhD

Baltimore-If you are considering buying a new electronic health record (EHR) system or updating your current one, make sure you spend enough time in the preparatory stage of system selection and vendor selection, says one expert.

Physicians need to determine what processes they have in their practice and how they would like those processes to look with an EHR. They should write down their practice workflow in areas such as scheduled and unscheduled patients, phone calls, and surgeries, and think about how these processes may be improved using an EHR, said Michael V. Boland, MD, PhD, who is associate professor, Wilmer Eye Institute and Health Sciences Informatics, and director of information technology, Wilmer Eye Institute, Johns Hopkins University, Baltimore.

When documenting the practice routines, consider the numerous details involved in each step, he suggested.

“It is inadequate to say that the patient checks in, is evaluated by a technician and then a physician, and then checks out. The documentation must include the details of each step, such as use of a paper chart or not at check in and notification of other office personnel regarding the patient and testing, for example. This documentation will provide a complete map of the flow of patients in the clinic and this map will differ for new patients, returning patients, emergency patients, and surgical patients,” he explained.

Reviewing your forms

Identifying forms used in a practice also is part of the discovery documentation process, as they are a proxy for important workflow steps, such as examination forms, test interpretation, agreements for surgery, or recommendations for a referral or a procedure for a patient, Dr. Boland said.

“These become a key piece of what will be recreated later and a conversion to an EHR is a good opportunity to redesign the forms if they are not working properly,” he noted.

Determining the roles of all practice personnel, i.e., physicians, technicians, managers, and administrative staff, is another major step as well. Remember that some staff members perform multiple duties.

“The resulting diagram will provide not only what is happening to the patient but also who is doing it. This is key information for recreating the practice needs in an EHR system,” Dr. Boland said.

Glaucoma practices, for example, have a lot of in-office testing. All testing equipment and software programs in multiple locations and across multiple devices need to be tied into the EHR.

Dr. Boland also pointed out that an ophthalmology practice can differ substantially from other types of practices.

“If you are considering an EHR system that can be used by a number of different specialties, be sure to choose one that works for ophthalmology,” he said. He suggested physicians read an article published by the Medical Information Technology Committee of the American Academy of Ophthalmology (AAO), “Special Requirement for Electronic Health Record Systems in Ophthalmology” (Chang et al. Ophthalmology 2011;118:1681-1687).

Another resource from the AAO is an annual survey completed by EHR vendors to determine how their systems work for ophthalmology practices. It asks about specific requirements that are important to ophthalmology, such as documentation of ocular findings using both text and drawings.

Picking a system

Once the activities and needs of the practice have been determined, generating a “request for proposals” document is the next step. This document specifies for potential vendors the required capabilities of a medical records system. The AAO website ( has an example of such a document.

There also are tools available to help physicians choose vendors. The AAO/American Academy of Ophthalmic Executives has compiled an EHR survey that assesses physician satisfaction with a list of various vendors. The AAO also provides online reviews of medical records systems from peers, he added.



Michael V. Boland, MD, PhD


Dr. Boland reported receiving lecture fees from Carl Zeiss Meditec.

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