EHR and Glaucoma: Perfect Together?

Despite some downsides, electronic records have practical advantages—especially if you’re managing glaucoma.

The switch to electronic health records is seen by many as—at best—a mixed blessing. In addition to the challenges that come with any kind of sweeping change, using EHR can be more time-consuming than using paper charts, and it comes with some pitfalls that don’t exist with the traditional system. On the other hand, it offers some significant benefits—and some of those benefits are of particular use to those of us who manage glaucoma.

Here, I’d like to discuss what some surveys are showing about doctors’ reactions to implementing EHR; review some of the benefits and downsides of using EHR; and highlight a few of the reasons EHR can be advantageous when managing glaucoma.

Reacting to Change
Recent surveys conducted by the American Academy of Ophthalmology provide a sense of where ophthalmologists stand in terms of adopting EHR. In 2013, 1,500 Academy members were surveyed about this; 500 replied. A third of the responding practices said they already had EHR; 15 percent had implemented EHR for some of their doctors or were in the process of implementation; and another third planned to implement EHR in the next couple of years. Of the doctors already using EHR, half were satisfied or extremely satisfied with their system. Forty-two percent reported stable or increased overall productivity; 20 percent reported that overall costs were stable or had decreased. Half of those using EHR said they would recommend their EHR to fellow ophthalmologists.

These numbers are hardly over-whelming, but most ophthalmologists might find them surprisingly positive. Even I was a little surprised that this many people were happy with their EHR systems, for the simple reason that they are a part of practice that doctors love to hate. However, if you ask physicians who have made the switch to EHR whether they’d be willing to go back to paper charts, only a small number say yes.

The data suggest that the answer to that last question changes over time as people get used to working with EHR. The longer a doctor has used EHR, the less likely it is that he’ll be willing to switch back to paper charts. In 2010, for example, a survey was done here at the University of Pittsburgh Medical Center. In that survey, about 30 percent of the people who had been using UPMC’s chosen outpatient system (EpicCare) for less than three months said they’d prefer to return to paper charts. But among those who had used the system for six months, the number dropped to 15 percent. The percentage was the same at one year, but by two years, it dropped to 5 percent.

Here at UPMC, we’ve looked at the acceptance of electronic records across our entire system. (UPMC en-compasses 20 hospitals with about 3,500 employed physicians and more than 60,000 employees overall; it’s a $12 billion-a-year global health enterprise.) In 2010 and 2011 we surveyed a random subset of our doctors and support staff. We found that about 70 percent of those surveyed thought EpicCare was an effective tool that gave good access to test results; that result didn’t change a year later. Asked whether the system was more accurate than paper charts, whether the switch had contributed positively to the patient’s care, and whether it made prescribing easier, 55 to 60 percent said yes in 2010; that rose about 10 percentage points by the following year. However, only about 40 percent agreed that the system improved communication, and only 15 percent felt that it increased their confidence in the data. Those numbers did not change between 2010 and 2011. (We’ll talk about the probable reason for those answers shortly.)

Earnings Impact
We also looked at return on in-vestment, using data from a four-year longitudinal study with a six-year follow-up. The four-year study looked at a fixed group of clinicians—people who were already in a stable practice—for the two years before implementation of the EHR, which took place in 2006, and then two years post-implementation. Our pur-pose was to look at the impact of implementing an ambulatory EHR in an academic ophthalmology practice, based on clinical productivity measures that could be quantified.

We found no difference in average number of office encounters per month between pre-implementation and post-implementation. There was an intentional drop in office encounters during the period of implementation itself, but then the numbers came right back up within a month of implementation; implementing EHR had no effect on volume. The same was true six years out; volumes were stable.

We also looked at charges and work relative value units, or wRVUs. The charges were unchanged from two years before to two years after implementation (see chart, p. 64), and there was no difference in charges per office encounter per faculty per month. The same thing was true six years later in 2014—there was no significant difference.

One area in which we did find change was testing; we found more testing was being billed after implementation of EHR than before. Prior to implementation the numbers for testing were flat (from 2004 to 2006). After implementation there was a big rise in testing. Then, from 2008 to 2014, we found no change. We think the reason for this is not that more testing was being done, but that more testing was being captured and billed for. When doctors have to fill out a paper superbill, they may forget to bill for some of the tests. Maybe they didn’t complete their interpretation of the results. With the EHR, every test is captured, and the system forces you to complete your interpretation. (For the record, the unchanged rate of income per office encounter did not reflect the change in testing income.)

EHR Downsides
Managing patients using EHR does have some drawbacks:
• It can be more time-consuming for the physician. About half of the physicians surveyed at UPMC felt that using EHR added a couple of hours to the workday. This is true, in part, because EHR forms require more extensive input than traditional paper records. However, 30 percent said there was no change, and about 10 percent thought it was actually more efficient and took less time than paper charts.

My experience has been that it does add time to the workday. Probably the biggest reason for this is that the electronic record requires you to provide much more information than you would provide in a traditional paper chart. Also, in a paper chart you can abbreviate things or use your own shorthand; that’s a lot faster than providing every piece of information the EHR system is asking for.

However, it’s worth noting that the extra work time people notice when using EHR may be offset—at least a little—by the fact that when you’re done, you’re done. At the end of the day, when you close the charts, that’s it; you’ve completed all of your required tasks. Among other things, the letters to referring physicians are done; they go out the same day or the next day. (Academic medical centers have typically been notorious for the lag between a patient being seen and communication with the referring physician. On the other hand, not every referring physician is thrilled to receive a five-page letter that’s filled with information the physician wasn’t looking for.)

• It’s harder to manage images. For ophthalmologists, one of the big-gest problems with EHR is storing and retrieving images, such as scans, photographs and visual fields. Because many systems don’t provide an easy way to do this, many doctors are using one system for text and another system for images. Sometimes the image system integrates with the text system; sometimes it doesn’t.

Another side to the issue of managing images is that many of us like to draw what we’re seeing. I used to draw what I saw on gonioscopy, and draw the optic nerve; I don’t do that any more because it’s just too cumbersome to do on a computer. However, not being able to create a drawing is somewhat offset by the fact that I have photos, OCTs and visual fields that I can access immediately. They usually give me the information I would have gotten from a drawing. (Plus, the information is presented in a more standardized and objective way.)

• Accuracy of chart information isn’t guaranteed. Based on my own experience with this system, I’d say that electronic records can be a very effective tool. However, I wouldn’t say the patient data is more accurate. Incorrectly entered data can and does occur. Also, the carry forward function may lead to the inclusion of outdated information. The carry forward function can speed up data entry, but you need to make sure that you change the relevant parameters to reflect your patient’s current status.

• Some systems require multiple log-ins. People are often annoyed by having to log in over and over again to access different programs. (Our system includes a tap-and-go feature that circumvents most of this. It saves us a lot of time during the day.)

• Interference with patient inter-action. Perhaps the most common objection to EHR is having to type information into the computer during the patient visit. The more time we spend typing, the less time we’re interacting with the patient. I think this is a tremendous waste of time for a doctor, so I use a scribe; some of the other physicians here at UPMC do the same. Scribes make things go much faster and allow you to interact directly with the patient throughout the visit, as opposed to sitting behind a monitor typing. Of course, there’s some cost associated with having a scribe in the room, but we have found that it increases your productivity enough that that the increase in patient volume far exceeds the cost of the scribe.

EHR Benefits
Despite the drawbacks listed above, the advantages EHR offers to the patient and physician are significant:
• No more lost charts. Many large practices have about a 10-percent rate of not being able to locate the patient’s chart when the patient shows up. That’s not an issue when you’re using electronic records.

• Remote access to records. With EHR you can access a patient’s record from anywhere in the world. That means you can address a problem your patient is having even if you hap-pen to be in Mexico, Europe or Asia.

• Electronic management of prescriptions. This is a huge bonus for the patient and the physician. For example, when you enter in the name of a drug you want to prescribe, the system can tell you whether or not that drug is in the patient’s formulary. This prevents follow-up phone calls from the pharmacy saying, “You prescribed this, but the patient’s insurance won’t pay for it. What else can the patient take?” You’ll know if there’s a problem while you’re still with the patient.

• More complete information about the patient. If your EHR is connected to a larger health system, the electronic record may contain all of the other physician information that has been entered regarding a given patient. That gives you a sense of the overall health of the patient and also helps to guide your prescribing (assuming the list of medications is up-to-date, which isn’t guaranteed, thanks to human error). For example, if the patient is taking an oral beta-blocker, there’s no point to prescribing a topical beta-blocker. It’s very helpful to have that clinical information at your fingertips.

• Notes are legible and easy to locate. The notes in a chart are al-ways easy to read, standardized and in the same place. I can’t tell you how many times during my training and as a fellow and faculty member I would look in a chart and be unable to decipher the prior notes. (This was true sometimes even if I had written the prior notes myself!) So having the information in a typed or graphical form, and being able to find it at a glance because you know where everything is on the electronic form is a big plus. Also, in the operating room the postoperative notes are usually templated and standardized, so they’re quick and easy to do.

• Patients can access their records. EHR technology also has a few profound advantages for the patient. One of those is giving patients the ability to get their own test results and medical history remotely at their convenience; that includes information about their allergies, medications and health problems, as well as lab and test results.

This is empowering for the patient. At the same time, it reduces the power of the physician a little, because the patient is in control of her own information. It’s something of a brave new world for us as doctors, because the patient can take that information and go anywhere. Of course, that doesn’t include digital records such as visual fields—so far. But some countries already have medical systems that make all of that available to patients, and I predict that will happen here within a few years.

• Easier doctor-patient communication. EHR makes it easy for the patient to communicate with the physician and the physician’s office online. Patients can schedule, confirm and cancel appointments; they can exchange secure messages with the physician; they can request a prescription renewal; they can get their eyeglass prescription automatically; they can even have an online e-visit with a physician to address some common conditions.

Benefits: Managing Glaucoma
Because of issues that are unique to managing glaucoma, EHR is particularly advantageous:
• It can help monitor adherence. EHR can tell you whether and when the patient’s prescription was filled, which gives you a hint regarding the patient’s adherence to therapy. You wouldn’t be able to easily get that information any other way.

• It can present and graph multiple parameters and how they’ve changed over time. One feature of some EHR systems (including ours) is so useful as to be considered disruptive technology—particularly if you’re treating glaucoma. Our system includes a program called Synopsis that allows us to see all of the discrete parameters that we’re tracking, over time, on-screen, all at once. We can look at different tests results obtained at different times and compare them directly. That means we can look at the visual field data from a series of visits; we can also look at visual fields and OCT data at the same time, allowing us to look for correspondence in structure and function. Even better, it allows us to graph up to four of those parameters simultaneously. (See example, p. 61.)In addition to graphing IOP over time, you can look at nerve fiber layer thickness and visual field index or mean deviation. This makes it easy to see whether or not your patient is stable or getting better or worse, and whether you have the IOP under good control.

The graphs can also show when interventions took place and what medications the patient was on during a given period, as well as when they stopped using a given medication. In our program, if you hover over a medication with the mouse, it highlights the period of time when the patient was on that medication. That makes it easy to compare what happened on different medications. When the patient was on timolol, this was the pressure; when the patient was on latanoprost, this was the pressure; on Simbrinza, this was the pressure. This program gives us information at a glance that in the old days we’d have to go thumbing through the chart to identify, and it gives it to us in a way that could not be presented on paper. We have the ability to compare different parameters on the fly.

Furthermore, we can link the text and image systems so that the patient’s test images come up automatically when you open that patient’s text-based chart. This is a big advantage, because the fewer steps you have to take to see what you need to see, the better.

This is one example of a disruptive technology that can be a part of EHR that enables the physician to provide better patient care. And it’s something you can only do with the help of a computer.

• It helps with patient education. Adherence is always a problem when managing a silent, often asymptomatic disease like glaucoma. EHR can help by making it easy to show the patient the problem on-screen and show how your interventions are impacting it. Seeing this on-screen can help motivate patients to make the effort to follow your instructions.

For example, I can show patients the trend of their IOP over the past two, five or 10 years, and what medications they were on during that time. I can even show them what was happening to their visual field and retinal nerve fiber layer during that time, although to avoid confusion I may just show the patient how the IOP changed and what effect each intervention and medication had. If the patient has a glaucomatous abnormality such as a nerve fiber layer loss or visual field defect, I can call up the OCT and visual field with a click of the mouse and show the patient exactly where the abnormality is. (Many programs highlight the abnormal area in red.) It’s much easier for patients to understand a visual presentation than a verbal description. That helps the patient understand why we’re using a certain medication, and it may even help encourage compliance.

Note: When graphing or comparing multiple results over time it’s important to remember that you may need to eliminate some results from the series you’re comparing or graphing. If you’re following a glaucoma patient over time and the patient had a bad day for some reason, or there was something wrong with the test at one visit, you can eliminate that test data from the series. More important, if the patient had a surgical intervention during the follow-up period, you can eliminate the test results from before the surgical intervention. If you fail to do that and you compare the results from the beginning, the patient will appear to be on a downward slope, simply because the surgical intervention changed the patient’s trajectory. It’s important to check for this, because even in academic medical centers you don’t always get the correct tests included in the analysis.

Another thing to remember is to manually store any part of the exam that isn’t automatically captured by the EHR system. In our case, I al-ways store the statistical-analysis portion of the visual field printout so that I can see what’s happened over time with the patient, instead of just comparing one field to the next. Our system doesn’t do this automatically; we have to upload the image into the image storage and retrieval system. However, there is a system called Forum, made by Carl Zeiss Meditec, that allows you to send the visual field information and the OCT information from their machines into a single database on a server; it acquires the data, as well as the image. It also allows you to remove confounding testing data from the database. I’m not sure if any other systems offer this option, but having software that will integrate the data and allow you to selectively include certain data points in the analysis makes data analysis much less cumbersome.

A Step in the Right Direction
Overall, I believe EHR is better both for the doctor and the patient, and that’s especially true when managing glaucoma. A good system will allow you to evaluate your patient’s progress over time much more easily than you could with a paper chart, showing the data graphically and interactively; it will let you interpret tests in a more intuitive fashion and compare structure and function, looking at tests of both simultaneously, without having to flip pages. It can be a great tool for patient education; it makes prescribing easier and prevents corrections because a drug wasn’t on the patient’s formulary; it lets you know if a patient hasn’t filled a prescription; and it makes it much easier for the patient to get hold of information and communicate with you. You’ll definitely be tracking tests better than you were with pen and paper; the system will capture all the tests that were done and help ensure that you get paid for your work.

Using EHR is a different experience than using paper charts, and it can be slightly more cumbersome. But for somebody taking care of patients with glaucoma, a good EHR system is a boon in so many ways that the advantages far outweigh the annoyances and disadvantages.  REVIEW

Dr. Schuman is Distinguished Professor, The Eye and Ear Foundation Endowed Chair in Ophthalmology and chairman of the department of ophthalmology at the University of Pittsburgh School of Medicine, professor of bioengineering at the University of Pittsburgh and director of the UPMC Eye Center. He receives royalties for intellectual property related to OCT licensed by MIT and MEEI to Zeiss; he otherwise has no financial interest in any product discussed in this article.

Joel S. Schuman, MD, Pittsburgh, 2016-08-05