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The implementation of electronic health records has had great impact on the way ophthalmologists spend their time. There are concerns that this has created inefficiencies, and that physicians now spend more time documenting, and less time with their patients, which is the opposite of what was intended.
Reviewed by Michael F. Chiang, MD
The transition from paper charts to electronic health records (EHRs) has created concerns about efficiency. In a Medical Economics journal survey of about 1,000 physicians nationally, 67% of respondents said they are dissatisfied with their EHR functionality, and 65% responded that their EHR created financial losses.1
Physicians at Oregon Health and Science University (OHSU) went live with EHR about 10 years ago. They have published studies showing how the volume of patients in ophthalmology has gone down slightly, whereas the time required by physicians has gone up.2
More recently, these physicians conducted a new study with two goals. The first part of the study looked at how pediatric ophthalmologists spend their time when in-room with patients.
The second part is a study of data to find out how much time is required for documentation with EHR in pediatric ophthalmology, and when that documentation is occurring.
Increasingly, physicians are pressured to see more patients in less time. But quality of care and customer satisfaction must be maintained. The answer to this dilemma is taking care of patients in multiple rooms at the same time, with technicians and orthoptists.
The first part of the study was a manual observation at OHSU using iPad apps. Observers followed physicians, technicians, and orthoptists during their day, and time-stamped what they did when they were in the room with a patient. Three categories looked at were examining the patient, documenting with the EHR, and talking to the patient.
One pediatric ophthalmologist was included in the study, and four other ophthalmologists (a cornea specialist, a glaucoma specialist, a retina specialist, and a general ophthalmologist) were also included for comparison.
The study found that the pediatric ophthalmologist spent an average of 13 minutes with each patient. Of that, 23% of the time was spent pointing and clicking in the EHR; 30% was spent examining the patient, and about 47% was spent talking to the patient’s family members.
For the other ophthalmologists in the study, there was a similar distribution, averaging 10 to 13 minutes per patient-29% of which was spent using the EHR.
From this, researchers noted that physicians do not have much time with each patient, and that while in the room with a patient, nearly 30% of physician time is spent documenting in the EHR.
“The purpose of this study is not to say if this is a good or bad thing for quality of care-I can see it being argued either way,” said Michael F. Chiang, MD, of the Casey Eye Institute at OHSU. “But it’s not much time, and a lot of it is spent on the EHR.”
Part 2: Big Data
Dr. Chiang explained that when he headed up of the medical information technology committee of the American Academy of Ophthalmology, he heard many physician complaints, such as: “I’m spending all day and all night charting in the EHR-I never used to do that with paper.”
To understand why that situation occurs, the group decided to do an EHR time-stamp analysis. EHR systems record every point and click of the mouse and log them, so researchers were able to determine which actions best corresponded with what the physician was actually doing during the patient visit.
The next step was to use the data to figure out how much time was spent documenting in the EHR, and whether it was during the exam or afterward.
Before doing that, the physicians wanted to validate the method of using the time-stamps, compared with the gold standard of manual time-motion collection using the iPad apps.
The five physicians followed in the study generated 3 million time-stamps in 1 year in the EHR audit log. About 400 patients were looked at to compare manual observation with the iPad with the EHR time stamps. The difference between them was only about 1 minute, which the researchers considered very similar.
Results showed that the pediatric ophthalmologist spent 9.9 minutes documenting each patient.
Of that, 46% of the time was during the patient visit; 41% of the time was during business hours after the visit, and 12% of the time was on nights and weekends. If 30 patients are seen in a day, that corresponds to nearly 5 hours per day documenting in the EHR. For the other four ophthalmologists, the distribution of time was similar.
Overall, researchers concluded that there are significant time requirements for EHR documentation and that pediatric ophthalmology seems similar to other ophthalmic subspecialties. The impact on patient care, however, remains uncertain.
EHR provides for better communication among different specialists, but may be creating a situation where physicians have less direct patient contact, due to time spent pointing and clicking in the system.
“We need to improve EHR design, to fix this problem,” Dr. Chiang said. “There may be a role for the American Association for Pediatric Ophthalmology and Strabismus in developing standards.”
The ability to collect data from EHRs also has a silver lining, he noted.
“Because we’ve got data about how long everything takes, we can use it for analytics,” he said.
With proper modeling, Dr. Chiang believes they can use the time stamps to determine how to schedule patients optimally and configure the clinic.
There are many issues to consider in improving efficiency of EHR systems. As physicians become more proficient with the system, the amount of time needed decreases.
Scribes can be considered as an alternative to physicians performing data entry. Dr. Chiang’s group used that approach in the past, and then stopped using scribes when physicians and staff became faster with using the system.
In addition, at academic centers such as at OHSU, residents and fellows assist attending physicians in this area to improve the amount of time spent face to face with patients.
Speech recognition software is another option to consider.
Finally, the type of system used (for example an ophthalmology-specific system versus a more general system) can make a difference, as can the data-entry abilities of each user.
1. Verdon DR. Physician outcry on EHR functionality, cost will shake the health information technology sector. Medical Economics. February 2014. http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/ehr/physician-outcry-ehr-functionality-cost-will-shake-health-informa?page=full.
2. Chiang MF, Read-Brown S, Tu DC, et al. Evaluation of electronic health record implementation in ophthalmology at an academic medical center (an American Ophthalmological Society thesis). Evaluation of electronic health record implementation in ophthalmology at an academic medical center (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2013;111:70-92.
Michael F. Chiang, MD
This article was adapted from Dr. Chiang’s presentation at the 2016 meeting of the American Academy of Ophthalmology. He did not indicate any proprietary interest in the subject matter.