By Adam J. Gess, MD
With the transition to electronic medical records well underway within ophthalmology, we can now begin to study the effects this sea change has produced. Any ophthalmologist who uses an electronic medical record (EMR) is aware of its effect on efficiency. But has it affected the completeness of our documentation? After all, one of the main claims regarding EMRs is that our charting will be more complete.
A study published this month in Ophthalmology by Sanders and colleagues explores this question. The authors matched 150 paper and electronic records, half occurring before their transition to EMR in 2006, and the other half after the transition. Three diagnoses were studied: glaucoma, age-related macular degeneration, and pigmented choroidal lesions. These three conditions were no-doubt selected based on the advantage that careful descriptions or drawings can offer. The authors created a scoring system for relevant parts of the documented record, and compared the scores between the written and electronic records.
Their findings suggest that EMR did make their documentation more complete at their institution. In regard to overall completeness of documentation, the EMR consistently outperformed paper records for all three conditions. While a few types of clinical descriptors—retinal vessels and location of choroidal lesions—seemed better described on paper, the majority fared better in the EMR. Slit lamp examination seemed to have the smallest amount of difference between paper and EMR records, while fundus examination and “overall completeness” showed the greatest variation.
The authors made several other interesting observations. First, and unsurprisingly, the EMR was more legible. The 150 EMR records had no illegible words, while 10 percent of paper records had portions that were illegible to the research team. It’s actually surprising that the incidence of illegible words in paper charts was that low. One would expect great gains in legibility from EMRs, and we hope this will translate into better cross-disciplinary care.
A second observation is that the EMR was, as expected, significantly longer than the paper records. Some of this length related to more complete descriptions of eye pathology, however much of it was due to copy-and-paste or all-normal text (i.e., fill a completely normal examination template) functionalities. While self-populated descriptors can help increase a physician’s efficiency when using an EMR, they risk over documentation of findings that aren’t actually seen, making the record more cumbersome to read.
A third interesting observation is that many of the physicians using the EMR used assessment language in the examination section, e.g. “good PRP” rather than pure descriptors of the appearance. This follows from the difficulty of using text to describe visual observations. None of the EMR charts included electronic drawings, while all of the paper charts included hand-drawn pictures, which is related to the difficulty in using current EMR systems to draw pictures. It remains to be seen whether our habit for drawing pictures in our charts will go away as EMRs become the norm or if future versions will provide easier ways for us to draw.
One consequence of the inability to accurately describe visual findings in a text-based EMR is a proliferation of imaging: fundus photography and optical coherence tomography particularly. Ophthalmic imaging is the most accurate way to capture a patient’s ophthalmic findings, but it can create difficulties integrating the imaging software with the rest of the EMR. One also wonders if a reliance on more imaging will create more costs to the system, since it costs nothing to draw pictures by hand.
Much of the challenge of transitioning to EMRs is the effect on clinical efficiency. While this paper did not address this issue, the authors did allude to the profound effects this transition has on physicians. Most practicing ophthalmologists have used paper charts their whole career, so the transition to EMRs is a fundamental shift in their practice patterns. Trainees and recent grads, however, have known only EMR documentation. It will be interesting to see if this demographic shift translates into more efficient use of EMRs or if it creates new and unintended innovations in the systems themselves.
The hardest effect to study about the transition to EMRs is the change it produces in physicians themselves. As the authors point out, prior studies have suggested that EMR use can affect physicians’ cognition and decision-making, and that these changes persist after going back to a paper records. One can hope that the “completeness” offered by EMR systems will translate into more precise clinical judgments by physicians. The danger is that too much attention will be paid to the medical record, and not enough to the patient sitting in the examination chair. However, most of our patients view our transition to electronic records as a positive development. Continued studies will be necessary to verify that this transition is in fact having positive effects on patient care, despite the difficulties inherent in implementation.