October 10, 2011

Ophthalmology Association Creates EHR Vision
By Robert N. Mitchell
For The Record
Vol. 23 No. 18 P. 8

The American Academy of Ophthalmology, a 30,000-member association for eye doctors and surgeons, recently released specialty-specific guidelines—the first of their kind since meaningful use incentives were announced—ensuring that certified EHRs support quality patient care, enhance physician-to-physician communications, and meet standards required by health reform policies. In “Special Requirements for Electronic Health Records for Ophthalmology,” the academy’s Medical Information Technology Committee (MITC) developed a list of the specific requirements needed to make EHRs as intuitive and efficient as possible for ophthalmologists and their practices.

Lead author Michael F. Chiang, MD, a member of the departments of ophthalmology and medical informatics and clinical epidemiology at Oregon Health and Science University in Portland, Ore., and MITC chair, says the guidelines include a list of 17 “essential” and six “desirable” EHR features involving clinical documentation, ophthalmic vital signs and lab studies, medical and surgical management, and ophthalmic measurement and imaging devices.

“Recent studies have shown that about 10% to 20% of physicians across all specialties have adopted an EHR. In 2007, the academy surveyed its members and published results the following year that found a 12% EHR adoption rate among ophthalmologists,” Chiang says. “We’re all faced with this challenge: We are starting out in the 12% to 15% range, with a goal of getting 85% of physicians onto EHRs within the next four to five years. However, in looking at EHRs that are used by ophthalmologists, many of my colleagues feel they are difficult to use.”

By creating the guidelines, the academy hopes colleagues will be better able to identify the components of a well-structured EHR. Chiang points out the requirements can enlighten others, too. “This is also designed as a guideline for vendors to better understand the needs of ophthalmologists. We also hope that this may help the Centers for Medicare & Medicaid Services and the Office of the National Coordinator for Health Information Technology in defining future meaningful use guidelines that will support the ability of ophthalmologists to provide the highest quality care,” he says.

Tailored Fit
Every medical specialty functions a bit differently. At ophthalmology practices, workflow tends to be complex. “In ophthalmology, there are a number of different users who document in the EHR,” Chiang notes. “Technicians, ophthalmic photographers, orthoptists, nurses, residents, and attending physicians all document in a shared medical record.”

For example, technicians guide every patient through a series of exams. “The technician performs a myriad of tests on the patient and writes things in the chart. Ophthalmic photographers then perform imaging studies before and/or after the physician sees the patient,” Chiang says.

The academy prefers EHRs that support general ancillary testing and are able to generate orders for and collect data from lab and ophthalmic PACS systems. This is currently a challenge because many ophthalmology EHRs do not support standards such as DICOM for storing and transmitting ophthalmic images.

“The academy urges the adoption of common data standards, such as DICOM for ophthalmic images, in order to optimize the delivery of critical patient information and enable physicians to provide the best in patient care,” Chiang says.

Another aspect unique to ophthalmology is that most patients have their eyes dilated at some point during their exam. Typically, patients will be seen by a technician, followed by a physician, before their eyes are dilated. Following dilation, patients are shifted to a waiting room to return later to continue the exam. “We have patients moving within the office at various stages of their exam. We must then document before and after and have a workflow piece that tracks their movement—all making ophthalmology EHRs difficult,” Chiang says.

Extensive use of hand-drawn sketches is another element of an ophthalmologist’s workday that doesn’t fit neatly into EHR configurations, many of which do not support drawings. “The hand-drawn sketches are such a fundamental part of the ophthalmologist’s culture—you sketch what you see,” explains Chiang. “Other specialists, such as urologists or general surgeons, may sketch but not to the extent that ophthalmologists draw and annotate their images.”

An anatomic drawing template may include a standard image of a retina or cornea on which a physician can draw and annotate abnormalities. Chiang says current EHRs rely primarily on keyboard- or mouse-based data entry without a useful mechanism for drawing or annotation.

Academy Recommendations
According to the academy’s report, for an EHR to be most conducive to an ophthalmologist’s workflow, it must incorporate features that capture, track, and display ophthalmic vital signs. Future meaningful use criteria that incorporate specialty-specific practice patterns and requirements would further encourage development and adoption of EHRs that are tailored to ophthalmologists’ needs, the paper notes.

Because ophthalmology is both a medical and a surgical specialty, any EHR must support documentation in and transitions between the office and the operating room. In addition to those recommendations, the academy would welcome EHRs that capture, track, and display vital signs of the eye, such as visual acuity.

In July, the MITC hosted a webinar in which representatives from 15 EHR vendors were urged to build the type of functionality described in the academy’s guidelines. As a result, in the coming months EHR vendors will be asked to address how their systems match the list of essential and desirable features. Information detailing vendor responses will be provided to academy members in the near future, and the academy will continue to work with vendors to help them understand and evaluate the recommendations.

“In creating this paper, we felt it would be helpful to put out the academy’s position. How is what we do as ophthalmologists unique compared to what other physicians do? The issues for ophthalmologists involve workflow, documentation, how to work with vendors, and how we think EHRs can be designed better to suit our needs and help deliver better care to the patient,” Chiang says. “What we’re doing is opening the communication channels between ophthalmologists and vendors to work together to improve the products and patient care. Our recommendations define what will make a system work efficiently within the unique workflow and data management needs of an ophthalmology practice.”

— Robert N. Mitchell is a freelance writer based in King of Prussia, Pa.