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What proportion of physicians will be using electronic health records (EHRs) by 2014? The federal government has set an extremely ambitious target—85 percent—and is investing billions of dollars in an incentive program that rewards physicians for “meaningful use” of EHRs. But throughout medicine, significant numbers of physicians are hesitant about making the leap from paper charts to electronic records. They cite the considerable amount of money, physician time and staff involvement necessary to make the requisite changes. In eye care, these concerns are compounded by the lack of ophthalmology-specific features in some EHR systems.

To address the issues surrounding EHR adoption among ophthalmologists, the Academy’s Medical Information Technology (MIT) Committee developed a set of consensus guidelines and recommendations. “Our primary goal was to create a multiphysician-authored paper that delineates how ophthalmology differs from other medical specialties in terms of workflow and how EHRs should be designed to account for these distinguishing factors,” said the committee chairman, Michael F. Chiang, MD, professor of ophthalmology, medical informatics and clinical epidemiology at Oregon Health & Science University in Portland. The committee’s paper was published in Ophthalmology,¹ and you can read it online at www.aao.org/one.

How Is Ophthalmology Different?

Work flow and procedures can vary from practice to practice, no matter the medical specialty, but the five points below are unique to ophthalmology, said MIT committee member and pediatric ophthalmologist K. David Epley, MD, of Children’s Eye Care in Kirkland, Wash.

• Patients receive medical and surgical care, and they are seen in the office and the ambulatory surgery center (ASC). “Although many EHRs allow for good charting documentation, there is often no practical way to record procedures performed in the office,” said Dr. Epley. “Or there may be no communication tools between the office and ASC to permit documentation on site at an ASC. Further complicating matters, if the EHR does not partition information properly or if it prevents notes from being recorded in a certain part of the practice, it becomes difficult to comply with documentation guidelines. Systems should also be equipped to merge medical history information that must be gathered from a patient’s primary care physician prior to performing surgical procedures.”
   
• Ophthalmology is a visually intensive specialty. “For many of us, drawing is a key component of notation during a patient encounter. It would be a setback to move to a system that does not allow for this capability,” he said
   
• IOP is more of a “vital sign” than BP. Some ophthalmologists occasionally measure blood pressure or weight, but very few track such vital signs on a regular basis. “However, we consistently measure ophthalmic vital signs—IOP, for example—and need to record and visualize these data over time,” he said. Some systems, particularly those not tailored to ophthalmology, may not support those functions.
   
• Lab results and radiology tests are less important than output from ancillary devices. “While we occasionally need to integrate lab data into a medical record, the basic inclusion of those types of tests is not essential for us. But we frequently perform studies using ophthalmic equipment,” said Dr. Epley. “So although the ability to incorporate reports or laboratory findings may be necessary, we also need the ability to import, for instance, a patient’s visual field tests, corneal mapping or OCT images. And the tests should be stored in the system in a manner that is usable and identifiable as part of a patient’s chart.”
   
• Ophthalmology is a high-volume specialty. “In order to see 50, 60 or 70 patients per day, we must be able to chart quickly and efficiently,” he said. “Multiple users in different locations throughout a practice may be entering data during a patient’s exam. There should be some consideration for how the EHR allows the practice to accomplish this.”

Some Functions Are Essential

With ophthalmology’s distinctive characteristics in mind, the Academy MIT committee created two checklists that were published in the Ophthalmology paper. The first list identifies 17 EHR features that are considered “essential” for safe and efficient patient care. The committee recommends that these be part of all EHR systems used by ophthalmologists. The second list includes six additional features that are considered “desirable” for further efficiency and improved quality of care (see page 13 of this month’s supplement, EHR Essentials, which you can download at www.eyenetmagazine.org). The two lists are intended to provide guidance to practices that are shopping for an EHR system and to provide guidelines for companies that are developing EHRs.

“Our goal was to keep the requirements fairly broad and explain in general terms what we need as ophthalmologists to care for patients,” said Dr. Chiang. “We did not want to make recommendations that were too specific or stringent because they might be difficult for vendors to achieve. Conversely, we did not want to make them too basic or easy because it would not advance our field. Given this balance, we anticipate that some vendors should be able to meet most or all of the essential requirements now. However, we believe that other vendors do not currently meet all of the requirements.”

What if you already converted to an EHR system that is not yet equipped to perform all these functions? “If your system does not currently possess all of these capabilities, vendors are often willing to make alterations in the software or create special templates to meet a practice’s needs,” said Dr. Epley. “Discuss your ideas with them and find out what modifications can be made and when.”

Evaluate Your Practice

What works for one ophthalmology practice may not work for another. Getting the most out of EHRs depends largely on the extent to which you assess your work flow and determine your practice’s individual needs. A system that is a good fit for your practice will greatly improve your satisfaction with the product, said Dr. Epley.

According to the committee, before purchasing an EHR system, you should consider:

• Ease of use
   
• Subspecialty mix of the practice and whether the system offers subspecialty-specific features
   
• Patient volume (some systems are better suited for use in high-volume clinics)
   
• Quantity and frequency of ancillary testing performed (determine whether and how each device can be integrated into the system)
   
• Number of office locations to be linked together (e.g., inquire about data security, backup features and data exchange)

See how other practices are using their EHRs. It also may be helpful to talk to people who are already using a system. “They can tell you what they like and do not like about it—and which functions it will and will not perform. A site visit can be quite useful for observing a product in action. Find a practice that is similar to yours in size and subspecialty mix that has been using the software you are interested in purchasing for a minimum of one year. Make a visit to see how it is used over the course of a day. It will give you great insight into whether or not it will work in your practice,” said Dr. Epley.

You also can seek advice from your peers in an online forum. Academy and AAOE members can go to the EHRs in Ophthalmology group via bit.ly/8Z6WwF; AAOE members also can go to www.aao.org/aaoe and click on “listservs” to participate in the e-talk forum.

Communicating With Regulators

In addition to assisting vendors and ophthalmologists, the MIT committee wanted to “create a framework to assist federal agencies when they are developing future guidelines for meaningful use,” said Dr. Epley. And progress is being made with the regulators, according to former AAOE chairman Albert Castillo. “The federal government is slowly beginning to realize that not all specialties are the same and that each has its own particular needs,” said Mr. Castillo, who provides management services for several practices in southern Texas. “During phase 1 of EHR implementation, attestation has been easy for practices. Phase 2 requirements have been delayed because the government realized that it is not feasible for all specialties to meet the same requirements.”
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1 Chiang, M. et al. Ophthalmology 2011;118(8):1681–1687.