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    What Do Ophthalmologists Think of Their EHRs?

    By the Academy Committee on Medical Information Technology (MIT)

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    Electronic health record (EHR) systems continue to evolve, but—according to a recent survey—they are still very much works in progress. This survey, which was conducted by the Academy and the American Academy of Ophthalmic Executives (AAOE), elicited scores of comments from EHR users, ranging from the positive (“Could not run the practice without it”) to the frustrated (“Requires many unnecessary clicks”) and the furious (“Abysmally bad!”). With those latter comments in mind, it is perhaps understandable that many ophthalmologists are eschewing EHRs in favor of handwritten notes and dictation.

    How long can ophthalmologists delay EHR implementation? Over the coming years, physicians will experience increasing pressure to implement EHRs, not least because of the prospect of payment penalties under the meaningful use (MU) program. In the short term, the complexity of the ICD-10 coding system will also motivate many practices to seek out EHR programs to help simplify coding. In the long term, CMS will continue to use reimbursement to push physicians toward EHRs, with the Merit-Based Incentive Payment System (MIPS) consolidating the Physician Quality Reporting System (PQRS), the Physician Value-Based Payment Modifier, and MU regulations into one program.

    Which EHR systems do ophthalmologists prefer? To help ophthalmologists select an EHR system—whether they’re implementing EHR for the first time or switching from one system to another—the Academy and AAOE have developed a range of resources (see “Use These Resources”), including a survey that asked EHR users about their systems. An initial survey in 2012 was followed by a second survey earlier this year. Some of the 2015 results are summarized below. The Academy also has been campaigning hard to make EHR regulations less burdensome (see “Lobbying for MU Relief”).

    Use These Resources

    To help members make informed EHR purchasing decisions, the Academy and the AAOE provide several services, including the following:

    An online forum. The Academy Forum provides a discussion group—EHRs in Ophthalmology—for members to exchange their perspectives and insights on and to ask questions about different EHR systems (

    A user satisfaction survey. The survey discussed in this article was developed by the Academy MIT Committee and the AAOE. It was modeled after the American Academy of Family Physicians’ user satisfaction surveys.

    A survey of EHR vendors. Academy staff asked EHR vendors to report whether their product meets the 17 essential and 6 desirable features of an ophthalmology EHR, as specified by the Academy MIT Committee.1 At AAO 2015, read the results of that survey in the Friday/Saturday Academy News, the annual meeting tabloid, which will also be posted online on Friday, Nov. 13.

    Additional EHR resources. Visit the EHR sections of the Academy website at and


    1 Chiang MF et al. Ophthalmology. 2011;118(8):1681-1687.

    The 2015 Survey

    The survey was emailed to a large sample of practices (5,000 Academy and AAOE members) selected randomly from across the United States.

    Survey caveats. As with the 2012 survey, the 2015 response rate was low (4.4%), the number of responses for each EHR system was small, and the responses represent individual opinions and impressions that are not validated by external sources.

    Survey respondents. A total of 217 Academy and AAOE members participated in the survey, versus 264 in the 2012 survey. The majority of the respondents (81%) had used their EHR system for 1 or more years, versus 43% in 2012.

    In this latest survey, 78% of respondents reported that they helped select their EHR system, 51% had used 1 or more previous EHR systems, and 94% rated their technology skills as at least “average.”

    Furthermore, 85% of respondents were in physician-owned ophthalmology practices, versus 64% in the last survey. Only 6% of respondents were in a university/medical school/academic medical center, versus 17% in the last survey; 3% were in hospital/HMO/integrated delivery systems, versus 11% in the last survey.

    Lobbying for MU Relief

    Improving the MU program has been the Academy’s biggest advocacy issue in recent months. Stage 2 is clearly not working—almost 80% of physicians utilize an electronic health record system, but less than 10% of all physicians have successfully participated in Stage 2, and only about 7% of all ophthalmologists have done so.

    Some improvements to the Stage 2 rules. The Academy has persistently pushed CMS to extend relief to physicians. On Oct 6, in response to those efforts, CMS finalized changes intended to ease the requirements of the program. Specifically, the agency reduced the 2015 reporting period from 1 year to only 90 days and dramatically eased the patient engagement requirements by, for instance, reducing the number of patients who need to view, download, or transmit information electronically from 5% of patients to just a single patient per reporting period.

    Major fixes needed for the Stage 3 rules. The government also published its final rules for Stage 3 of MU. In 2018, all physicians will be required to meet the Stage 3 requirements, which—as currently formulated—would be even more burdensome than the Stage 2 requirements and extremely difficult for most ophthalmologists to meet. The Academy is working with the AMA and specialty societies in urging CMS to fix the controversial Stage 3 requirements.

    Supporting FLEX-IT 2. On the legislative front, the Academy backs the efforts of U.S. Rep. Renee Ellmers (R-N.C.) to bring permanence to some of CMS’ temporary fixes. Her proposed legislation—the Further Flexibility in HIT Reporting and Advancing Interoperability (FLEX-IT 2) Act—also offers solutions to some physician hardships that CMS has yet to address.


    Help make EHR regulations less burdensome. It takes only a couple of minutes to send a message to your U.S. House representative in support of Rep. Ellmers’ legislation. Go to

    EHRs in Use

    Altogether, there still is not much consolidation in the EHR marketplace, as ophthalmologists reported using 37 different EHR systems, versus 40 in the last survey.

    In the 2015 survey sample, there were 15 EHR systems with at least 5 respondents: Medflow (29), NextGen (27), Epic (14), MDIntelliSys (13), Compulink (13), EyeMD EMR (12), Modernizing Medicine (12), Practice Fusion (9), ManagementPlus (8), SRSsoft (8), iMedicWare (7), MDoffice (7), IO Practiceware (6), NexTech (6), and ifa united i-tech (5). 

    In the 2012 survey, the top 3 companies were the same, but the order was different: Epic (47), NextGen (42), and Medflow (26).

    Relax and Learn at AAO 2015

    This year’s annual meeting includes 4 EHR-related social events.

    AAOE EHR User Group Meeting. When: Saturday, Nov. 14, 3:30-5:00 p.m. Where: Casanova 501. Access: Free.

    AAOE EHR Reception (sponsored by Medflow). When: Sunday, Nov. 15, 4:30-6:30 p.m. Where: AAOE Member Lounge on Level 1. Access: Free.

    Using the IRIS Registry: Idea Exchange. When: Monday, Nov. 16, 3:30-4:30 p.m. Where: Academy Resource Center (Booth 2632). Access: Free.

    AAOE EHR Reception (sponsored by MDoffice). When: Monday, Nov. 16, 4:30-6:30 p.m. Where: AAOE Member Lounge on Level 1. Access: Free.


    For a full list of EHR-related events at AAO 2015, see page 14 of this month’s EyeNet Extra: Do More With Your EHR.

    User Satisfaction

    Overall, the survey again found mixed reviews in the following 5 categories: 

    • Ease of use. A little less than half of respondents said that their EHR was easy to use (48% versus 55% in 2012).
    • Patient volume. About half of respondents stated that their EHR system had a positive or neutral effect on their patient volume (52% versus 56% in 2012).
    • Efficiency. About a third of respondents said that their EHR system had a positive or neutral effect on efficiency (35% versus 42% in 2012). 
    • Meaningful use. Fewer respondents reported that it was easy to satisfy the MU requirements compared with the 2012 survey (43% versus 67% in 2012).
    • Net income. Fewer respondents indicated that the EHR had a positive or neutral effect on net income (38% versus 44% in 2012). 

    EHR Pros and Cons

    Respondents were asked to cite the best and worst features of their EHR system.

    Favorite features. Overall, users listed the following attributes among the best features of their EHRs: remote access to records, capability for better documentation, legibility, ability to share notes with other physicians, ability to see notes from other physicians, and e-prescribing.

    Most frustrating features. Respondents reported that the worst characteristics of their EHRs included the following: cumbersome data entry, which slows workflow (too many clicks, especially when trying to meet the MU requirements); lack of linkage with diagnostic equipment; poor drawing capabilities; inability to customize at the user level; and lack of good technical support from the vendor.

    Results for 3 of the Survey Questions


    After reviewing the survey results within the context of today’s political environment, here are some conclusions and recommendations.

    Still a fragmented market. Although many EHR systems are used by ophthalmology, the market is dominated by a handful of them.

    Need to improve data entry and navigation. Many users are frustrated by the number of clicks needed to move around the medical record, especially the additional clicks necessary to satisfy the MU requirements.   

    Need for increased interoperability. Users are frustrated over their EHRs’ lack of interoperability with other EHR systems and with the myriad diagnostic instruments found in the ophthalmology office. CMS hopes that its MU regulations will improve matters. The recently announced rules for Stage 3 of MU put a greater emphasis on interoperability, and EHR vendors will need to overcome significant hurdles in intersystem communication.

    EHRs are here to stay. At some point in the future, all ophthalmologists will be documenting patient encounters via EHR and exchanging information electronically with each other, with primary care doctors, and with patients. Until then, ophthalmologists must keep up with the changes mandated by the government, many of which are not applicable to the practice of ophthalmology. In order to minimize EHRs’ negative impact on the practice of medicine and surgery and to maximize the positive influence on patient care, it is imperative that ophthalmologists join with the Academy to shape the changes ahead (see “Lobbying for MU Relief”).


    * Committee on MIT: Michael Boland, MD, PhD, K. David Epley, MD, Thomas Hwang, MD, Michele Lim, MD, Aaron Lee, MD, Colin McCannel, MD, Arvind Saini, MD, MBA, David Silverstone, MD, and Linda L. Wedemeyer, MD

    November 2015 Practice Perfect Web Extra