Eyeworld

18 Ophthalmology Business • March 2018 charts, he said, is they aren't subject to power outages or server failures. When hurricanes hit Florida in 2017, for example, Dr. Mendelsohn said their electronic records were down for 5 days, forcing staff to take handwritten notes and input them electronically later. Dan Montzka, MD, Golf Coast Retina Associates, Clearwater, Florida, said EHR efficiency has improved im- mensely since when he first left paper records for electronic 14 years ago. He estimated that he spends about 1 minute on the EHR during a patient's exam time, but time spent on an EHR can vary widely depending on the system chosen. "You have to have a system that has been responsive to user input over time and has been willing to improve and listen to the end user to try to make the workflow better," Dr. Montzka said, adding later that if you are on a well-designed system, you have to take the time to learn it and customize it to your own use. Where do we go from here? Michael Boland, MD, associate professor, director of information technology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, in a published commentary about this study wrote that, in general, "it is hard to know if this is too much time with the EHR, too little, or just about right." 2 Other research, he continued, showed differences between medical special- ties in time spent using the EHR and broke down the time spent on spe- cific EHR tasks, such as documenting patient findings or reviewing data. "Beyond just time spent on EHR-related tasks, it will also be important to ask what those particu- lar tasks are. It will then be possible to make value judgments about the importance of each task—is it worth the time spent? We might be willing to have increased documentation few tools that everyone uses … not even every ophthalmologist uses an ophthalmoscope. Yet the EHR is something that every physician uses. Despite that, we get no training to use it. … The time that's dedicated to teaching ophthalmologists how to use the EHR, which is so fundamen- tal to medicine, is sometimes zero," Dr. Chiang said. In addition to designing systems that are more functional for clinical use and being well educated on how to use them, Dr. Chiang said having a standardized method of documen- tation within the group can help. "It makes it confusing for staff and physicians when everyone documents differently. Most practic- es use the same paper templates for everyone, so everyone knew where to look to find information. It's my ex- perience that different doctors even within the same subspecialty don't use [the EHR] the same," he said. Getting more staff members involved with the EHR can reduce the amount of time physicians spend on it as well. "For example, we have technicians who are very adept at using the EHR. We spend time with them working out what they can help document vs. what we can help document," he said, adding that some practices are starting to employ scribes for this purpose. Alan Mendelsohn, MD, Eye Surgeons & Consultants, Hollywood, Florida, has had a medical technician or scribe take notes during his ap- pointments for all of his 30 years in practice, even when he was still using paper charts. Using a scribe allows him to maintain eye contact with the patient during the exam and gives him more time to explain things and put an emphasis on preventative care. While Dr. Mendelsohn said he understands the need and benefits of EHR, he thinks he was more efficient with paper charts and found them more reliable. An advantage of paper While Dr. Chiang said the study doesn't answer why this is the case, he speculates that those with higher patient volume might be seeing more standardized patients. "If you're doing a similar thing with many patients, it's a stereotyped work- flow," he said, noting that this could apply to the EHR use in these cases as well. Physicians could use macros to streamline their documentation, they could be copying and pasting certain text, or they could be clicking "normal exam" and autopopulating EHR fields, making their documen- tation process faster than physicians who might see more complex and nuanced cases, Dr. Chiang said. It should also be noted that all ophthal- mologists in the study spent at least 5.8 minutes per patient encounter using the EHR. This, Read-Brown et al. wrote, suggests "that there is a minimum amount of EHR time need- ed per encounter." Improving EHR efficiency While physicians might decry the amount of time they spend using the EHR, the electronic documentation system is not going away, Dr. Chiang said. "I don't think there is any real- istic way the EHRs are going to go away … there are too many clini- cal, compliance, quality assurance, and public health-type reasons that that's not going to happen," he said. "What I'm hoping this research does is start a dialog about how we can make these systems better and how we make them more efficient. Part of that is going to involve designing better systems. How do you design better systems? You've got to get doc- tors to talk to the people who design the systems." From there, Dr. Chiang said doc- tors need to be adequately trained in using the selected EHR system. "Of all the different tools that we use as physicians, there are very continued from page 17

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