IMPACT ON CLINICAL VOLUME
This study demonstrates that it is feasible for a high-volume academic ophthalmology practice to implement and use an EHR successfully. Some ophthalmologists throughout the country have been using EHRs for years.11 At the same time, there have been well-known reports of failed information technology system implementations in ophthalmology and other fields.37–39 We found that ophthalmologists within the department successfully transitioned to using the EHR system regardless of subspecialty, provider age, gender, or length of practice (Table 1 and Figure 1). Previous research has suggested that although younger clinicians might be expected to use information technology more fully, the culture of the practice may be a more critical factor affecting the level of adoption.40 There was strong commitment to EHR implementation at the study institution, both throughout the university and within the ophthalmology department, as well as clear statements of system objectives, an experienced vendor, a departmental project champion, and solid physician commitment to planning and deployment. These factors have consistently been shown to be strongly associated with successful outcomes in the project management and computer science literature, and we believe they must be considered by ophthalmologists before planning EHR adoption.37,38,41–46
There was a small decrease in clinical volume compared to baseline values with a paper system among the 23 stable providers in this study. In particular, there was a 12% overall decrease in volume during the first quarter after EHR implementation, followed by a subsequent slow return to near baseline over time (Figure 1). Of course, there are potential limitations of using clinical volume to assess impact of an EHR system. For example, the practices of younger providers may tend to grow over time, whereas the practices of older providers may tend to shrink over time. In this study, we normalized for these practice variations by defining a set of “stable faculty providers” who were practicing the 5 months before and after the 3-year study period. We believe this is a reasonable method for including the maximum number of study providers while excluding those with atypical practice situations, but acknowledge that there are other confounding factors unrelated to EHR implementation that may affect the practice volumes of the providers in this study. Finally, we note that clinical volume may demonstrate seasonal variation. Baseline clinical volumes using paper documentation before EHR system implementation were available only from November 2005 through January 2006. Although the number of clinic visits to family physicians has not been shown to decrease during winter months,47 providers in this study tended to have lower clinical volumes during the winter (Figure 1). This may bias the baseline pre-implementation values to be somewhat lower than typical pre-implementation clinical volume. Despite these limitations, we do not feel these findings demonstrate any significant change in clinical volume at the study institution during the several years after EHR implementation.
In the ophthalmology field, similar studies examining the impact of EHRs on clinical volume have been limited. A national survey of ophthalmologists working in practices with EHRs found that 34% felt that clinical productivity 6 months after implementation had increased, 30% felt that it was stable, 15% felt that it had decreased, and 21% were unsure.11 In 2010, an informal survey of 150 pediatric ophthalmologists at a national meeting estimated that 20% to 30% had implemented an EHR in their practice (approximately half within the past year). Among ophthalmologists using an EHR, none estimated that their clinical efficiency increased or remained stable, approximately one-third estimated that their efficiency had decreased by 10%, and approximately two-thirds estimated that their efficiency had decreased by 30% or more (Biglan AW, written communication, October 4, 2011). Within other fields, investigators have suggested that there may be an initial decrease in productivity after EHR implementation in primary care offices, with subsequent recovery.27,48 In contrast, a different study involving five ambulatory clinics at an academic medical center suggested that there was no obvious slowing of office workflow or productivity with EHRs.49 Finally, a study examining productivity before vs after implementation of the same EHR (EpicCare) as at our institution showed a small increase in clinical volume and charges after implementation.50 It is likely that the impact of EHRs on clinical volume varies based on differences in the specific system, implementation and utilization process, office workflow, and individual providers.
The system (EpicCare) implemented in this study was used throughout the university medical center. Although this provides advantages with regard to data exchange throughout the institution, there are concerns that large hospital-wide EHRs may not be optimally designed for the unique documentation and workflow requirements of ophthalmologists.26 Despite these concerns, this study found that there were no significant differences with regard to clinical volume after EHR implementation in the ophthalmology department compared to primary care specialties (Figure 2, top) and other similar medical and surgical specialties (Figure 2, bottom). Examining and understanding the differences among different medical specialties that affect ease of EHR adoption is beyond the scope of this study but is an important area for future research that will require detailed analysis of each individual field.
Higher-volume ophthalmology faculty providers in this study had an increasing clinical volume trend, whereas lower-volume providers had a decreasing clinical volume trend. Given that ophthalmology is a fast-paced specialty with many potential documentation challenges associated with new information systems, it might be expected that EHRs would hamper high-volume practices more than low-volume ones. For example, one study found that having more nonclinical work hours was associated with increased use of clinical information technology.51 On the other hand, EHRs may also provide opportunities for optimizing volume and efficiency through improved communication with other health care providers, rapid documentation of common findings through automated templates, electronic data exchange, access to computer-based practice guidelines and information resources, and improved practice management and charge submission.52–57 From this perspective, one possible explanation for this study finding is that higher-volume faculty providers may have been motivated to exploit these new strategies for leveraging EHRs to improve office workflow out of necessity to maintain their practice volumes. Another possibility is that providers who tend to become “higher-volume” do so because of underlying personality traits, and that efficient utilization of EHRs is simply another manifestation of those same traits. Finally, it is possible that higher-volume providers may have had more ancillary support and other clinical resources than lower-volume providers. Additional qualitative research studies may help elucidate the factors related to these differences.58 Interestingly, there were no statistically significant relationships between volume trend and provider age, gender, or subspecialty division. It is our anecdotal observation that individual variations among different providers at our institution may be larger than any differences that might be explained by these specific factors (eg, age, gender). Future studies involving more providers, perhaps from other institutions, would provide more insight into these issues.
IMPACT ON PROVIDER TIME REQUIREMENTS
Despite these findings suggesting that clinical volumes have been relatively stable after EHR implementation, it has been our anecdotal experience that many faculty providers feel that the transition toward electronic systems has been difficult. One possible explanation is that in many paper-based workflows, ophthalmologists often complete all clinical charting before the patient leaves the office. In contrast, a key study finding was that faculty providers using an EHR completed a significant proportion of clinical documentation outside typical business hours. Specifically, faculty providers using the EHR system in this study completed 32% of clinical documentation during weekday nonbusiness hours or on weekends (Figure 3). In fact, this analysis may underestimate the true burden of EHR documentation because much of this work completed during “weekday business hours” may have actually been done during scheduled academic, vacation, or administrative time during standard business hours from Monday through Friday.
Examination of the underlying reasons for these nonstandard documentation times was difficult because there were no baseline data available for chart completion time using paper systems. To address this issue, we performed time-motion comparison59 of two faculty providers (one retinal specialist and one pediatric ophthalmologist) who continued to work in satellite clinics using paper documentation. This showed that the EHR system required significantly more nonclinic documentation time and significantly more total time compared to paper charting (Table 4). These latter findings support the notion that providers using paper-based methods are often able to complete clinical documentation, billing documentation, and dictations to referring physicians during standard clinical time. For example, “Provider B” (pediatric ophthalmology) required no nonclinic time during these study sessions. Although the mean difference of 6.8 minutes per patient between EHR and paper calculated in this study may seem short, this translates to over 2 hours of additional time during a typical half-day clinic session with 20 patients.
Of course, findings from only two providers over 3 days may not be generalizable to other providers at our institution and elsewhere. Although the same two faculty providers were working at both the satellite clinics (using paper) and the academic medical center (using EHR), there were other differences between these sites that may have affected efficiency. Potential differences include the following: (a) Clinical staffing. For the pediatric ophthalmology provider, patients at the satellite clinic were seen by only an orthoptist and the faculty provider. In contrast, the academic center was more heavily staffed, and patients were often seen by technicians, orthoptists, and residents or fellows. For the retina provider, the satellite clinic was staffed by two technicians. In contrast, the academic center was staffed by three technicians. In fact, this additional technician was felt to be required because of slower data entry using EHR. Although it was the same staff members working at satellite and academic clinics with both the retina and pediatric ophthalmology providers, the availability of additional staff to assist at the academic center may have biased the time requirements in either direction. (b) Case mix. Although it was the anecdotal feeling of the two providers that there were not significant systematic differences in disease severity between patients at the satellite and academic clinics, additional data collection would provide more insight into this question. (c) Workflow. Other than the differences above, the workflow at satellite and academic clinics was similar for both providers. For example, neither clinic employed “scribes,” and letters were sent to referring physicians in both clinics when felt to be indicated. In fact, it was the anecdotal impression of one provider that he generated more letters to referring physicians at the satellite office, and the impression of the other provider that “most of my outside satellite-clinic work is the process of sending letters as I can do almost all billing and documentation on-the-fly in the satellite clinic—probably in about the amount of time it takes me to log in and select my patient’s chart with the EHR.” Overall, we note that there were no significant differences in time requirements for either provider among the 3 days examined (data not shown). We are not aware of any other studies that have systematically attempted to examine this issue, perhaps because time-motion data are challenging to collect. For all of these reasons, we feel that these study findings are consistent with our personal observation that ophthalmology EHR documentation requires more time than traditional paper-based documentation.
With regard to the lengths of time required to complete EHR documentation, we found that these were often significant, and that there were some striking variations. For example, EHR documentation was completed for 50% of all patient encounters within 4 hours and for 75% of all patient encounters within 2 days. However, documentation for the remainder of patient encounters required nearly 3 weeks to approach 100% completion (Figure 4). Among different providers, there were some who consistently completed all encounters relatively quickly (eg, we are aware of several providers who perform EHR documentation in the office for each patient), and other providers who consistently required much more time (eg, we are aware of several providers who wait until evenings or weekends to complete EHR documentation). It is difficult to determine with certainty whether faculty providers completed charting during off-hours because they found EHR charting too time-consuming to perform during the patient encounter, because they are less facile with the EHR system, because they preferred the flexibility of performing documentation during nonclinical time, because they felt documentation during the clinic visit would interfere with the patient-physician relationship, or because of other reasons.
Finally, the length of time required by study providers to complete EHR documentation had a statistically significant tendency to increase during the 3-year study period (Figure 5). We suspect that this increase was caused by a combination of factors, such as evolution in workflow patterns (eg, more providers completing EHR documentation during evenings and weekends) and a gradual increase in clinical volume over time. In addition, encounters involving resident or fellow trainees required significantly more time for completion than encounters without trainee involvement immediately after EHR implementation, although this difference narrowed quickly (Figure 5). The underlying reasons for this discrepancy are not clear, but are presumably because of a learning curve involving faculty-trainee interaction while using the EHR together. Important motivating factors for EHR adoption include improving quality of care, decreasing the incidence of medical errors, and decreasing the cost of care.2,6,7,13,14,60,61 However, it is conceivable that documentation of examination findings, diagnostic impressions, and management plans long after the clinical encounter could affect the ability of providers to perform these tasks accurately because of reasons such as memory and fatigue. These issues warrant future research and will be important for ensuring the timeliness and quality of care.
Taken together, these findings involving clinical volume and time requirements suggest that providers need to work longer to examine a similar patient volume using EHRs compared to paper systems. There are no previously published papers to our knowledge examining documentation speed with EHRs by ophthalmologists. Formal investigations involving time efficiency of ambulatory EHRs compared to paper documentation in other medical specialties have reached varying conclusions.62 Several studies examining clinical documentation times by nurses found that EHRs required more time than paper-based systems,63,64 whereas others have showed that EHRs required less time.65,66 Published studies in primary care settings have reported that EHRs were associated with increased documentation time,67–69 yet studies in intensive care unit, psychiatry, and anesthesia settings have found shorter documentation times with EHRs compared to paper systems.70–72 A time-motion study found no difference in the clinic time required for EHR documentation by primary care physicians compared to baseline times using paper documentation, although that study did not consider nonclinic time requirements.73 Kennebeck and colleagues74 found that patient length of stay in a pediatric emergency department increased by 6% to 22% after EHR implementation despite additional providers postimplementation, but those delays were noted to resolve after 3 months. A study utilizing survey reporting demonstrated that 66% of physicians perceived that EHR implementation increased their work amount, although RVUs per hour increased significantly compared to pre-EHR baseline values.75 In a different report utilizing survey methods, Bloom and Huntington76 showed that physicians spent 13 to 16 minutes documenting each patient encounter, and found that physicians and staff felt that the EHR was adversely affecting patient care and communication among clinic personnel. Our study builds upon this published literature by examining the ophthalmology domain, by including analysis of raw data involving clinical volume and encounter times with EHRs vs paper methods, by examining trends over several years involving multiple ophthalmic subspecialties and medical specialties, and by correlating with faculty provider characteristics.
IMPACT ON OPHTHALMIC DOCUMENTATION AND CODING
Although this study found that EHRs are associated with increased time requirements but little or no increase in clinical volume, it is important to note that a potentially important benefit of electronic records is improved quality and completeness of documentation.77–80 For example, information entered into the medical record by physicians may be checked by clinical decision support algorithms to prevent potential medical errors, analyzed through retrospective research studies, used to find patients eligible for prospective clinical trials, and used to populate large-scale public health data repositories.6,81,82
Lawsuit and legal complications
Integrated EHR systems have the potential to significantly improve patient safety and quality of care within the hospital; however, there are many significant barriers to implementation that must be addressed by leadership before committing to hospital-wide adoption. Before transitioning to an EHR system, organizations must identify and dedicate appropriate administrative and medical personnel to work on implementation, which includes a dedicated liaison between the organization and EHR vendor (5). Identifying a team lead and site ‘champion’, along with practicing appropriate change management techniques, is more likely to lead to a positive transition phase (6). Communication with the EHR vendor about specific needs and workflow design should be prioritized to ensure that the system is ready for full implementation when it is scheduled to ‘go-live’. Success depends on a seamless conversion from one charting system to another, and there is no guarantee of data integrity during the transition phase; however, a well-planned and executed implementation can minimize some of these risks (7).
If implementation is done poorly it can increase the risk of error, in turn exposing physicians and hospitals to potential medical malpractice lawsuits and other legal complications. Some studies have shown that medical error, adverse patient events, and even mortality can increase when a new EHR system is introduced (1). This can be explained through an increase in user error while entering information into an unfamiliar IT system and EHR system-wide crashes that create problems in care processes or limit access to important patient information (1). A more recent study published in the British Medical Journal found that in the immediate 30-day period before and after a single day EHR roll-out at 17 U.S. hospitals, there were no adverse short-term effects on patient safety, suggesting that accounts of negative experiences at a single hospital can be problematic when evaluating success of implementation (8).
Legal precedent suggests that providers are responsible for reducing risk during the transition phase, with one federal court ruling that the hospital had a duty to ensure that physicians had timely access to lab results while an electronic system was installed and operationalized (1). The hospital had the responsibility to maintain effective workaround solutions to minimize disruption to patient care and clinical decision-making, in effect requiring duplication of work during the transition phase. If the implementation is short lived, this requirement is a nuisance that disappears relatively quickly. Should EHR system installation take longer than anticipated or the project meet with unexpected delays, processes are slowed, decision-making is impacted, and patient care potentially jeopardized. Furthermore, the Health Insurance Portability and Accountability Act (HIPAA) clearly states that hospitals are solely responsible for their EHR system, including how it is used (9). This requirement places significant burden on hospitals to ensure appropriate policy and technical support are readily available, all at significant cost to the organization.
EHR systems also increase the amount of data and documentation available for review in the event of a medical error or adverse event. In one case where a patient was left as a quadriplegic after surgery, the competency of the surgeon was originally called into question, but when EHR metadata was further analyzed it was discovered that a time stamp raised question as to whether the anesthesiologist was present for the entire surgery (7). This level of detail available to prosecutors may heighten the risk of malpractice allegations among an entire team of providers (7).