Opinion
EDITORIAL
Electronic Health Records and Ophthalmology A Work in Progress Michael V. Boland, MD, PhD
The Health Information Technology for Economic and Clinical Health Act adopted in 2009 was designed to increase the use of electronic health records (EHRs) by US health care professionals and hospitals via a system of incentive payRelated article page 668 ments. As of December 2014, almost 340 000 professionals received these payments via Medicare and almost 170 000 professionals received payments via Medicaid. These professionals received more than $10 billion in payments for EHR use.1 As intended, the Health Information Technology for Economic and Clinical Health Act has had a clear effect on the adoption of EHRs, with the most recent estimates showing almost 80% of US physicians using one.2 These incentive payments for the meaningful use of EHRs will end in 2016 and professionals who choose not to use an EHR will begin to experience penalties that may increase to 4% of payments from Medicare by 2018. Therefore, it is a reasonable time to determine where ophthalmology stands in terms of the adoption and effect of EHRs. Our most recent evidence regarding the adoption of EHRs is a survey of American Academy of Ophthalmology (AAO) practices conducted in 2011.3 Based on those responses, we would expect that approximately 80% of ophthalmology practices have an EHR by now. This number corresponds closely to the rates found for medicine overall in 2013.2 Within these overall rates of adoption, some significant differences are hidden in terms of what kinds of practices have made the change to an EHR. A report on the adoption of EHRs by the Centers for Disease Control and Prevention in 2012 found that practices with older physicians, smaller practices, practices owned by physicians, and surgical specialty practices were all less likely to have implemented an EHR.4 Similar differences were noted in the AAO survey mentioned earlier in which smaller practices, physician-owned practices, and ophthalmologyonly practices were all less likely to be using an EHR. Beyond these differences, the 2011 AAO survey found practices were less satisfied in a number of ways with their EHRs compared with those surveyed in 2006. However, the rate of adoption is only 1 aspect of EHRs and it is important for our specialty to determine the effect of EHRs on practices and patients. How is EHR adoption going in ophthalmology? I believe the answer is that it depends. By that I mean the experience of EHR use in ophthalmology varies from practice to practice (even with the same EHR product) and even from subspecialty to subspecialty in the same department at large institutions. I say this based both on anecdotes related to me as a member of the AAO medical informajamaophthalmology.com
tion technology committee and on a growing body of evidence in the literature. The work by Singh et al 5 in this month’s issue of JAMA Ophthalmology supports this view in that it reported an overall successful installation of an EHR while also demonstrating that some divisions within their department experienced increased patient volume and revenue and some saw declines. Other work in similar academic practices has also shown that it is possible for practices in those settings to be successful.6,7 Within my own department, we were able to show that an EHR transition altered the time spent on various activities in our glaucoma clinic but did not decrease productivity or alter patient satisfaction with their encounter.8 Outside of academic practices, we have a real lack of published evidence regarding the success or failure of EHRs. We have to rely on the kinds of stories that my fellow AAO medical information technology committee members and I hear on a regular basis. We have all been asked at one time or another, “which EHR should I buy?” or “I am unhappy with my current EHR. What do I do now?” Such questions are frequently coupled with a story of a failed EHR deployment, either on their part or on the part of a colleague. If we are being honest in our responses to these questions, we have to tell them as I suggested earlier that it depends. In this case, it probably depends on ill-defined attributes of each practice. Just as there is no single architectural plan for every ophthalmology practice’s physical environment, there is no single EHR that will work well for every practice or even every practice of similar size and specialization. How do we obtain the knowledge necessary to determine the success or failure of an EHR in ophthalmology and the factors that lead to that outcome? First, we need to define standard metrics by which we will assess the effect of an EHR on a practice, the physicians using it, and the patients whose health information is being collected and stored. Ideal metrics would be insensitive to changes in other factors such as the number of professionals in the practice across time and changes in reimbursement by health insurers. There are clearly ways these non-EHR factors could result in an EHR being blamed (or credited) for changes that would have occurred with or without the EHR. In addition to more consistent metrics, we also need a more systematic way to communicate those metrics with one another. One possible approach to this need is the online system the AAO has created for EHR users to evaluate their systems.9 Because many EHRs on the website have too few reviews, because they are not collected in a systematic way, (Reprinted) JAMA Ophthalmology June 2015 Volume 133, Number 6
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a Cornell University User on 09/08/2016
633
Opinion Editorial
and because the questions asked do not address the possible reasons for success or failure, the data currently available are not adequate to determine risk factors for success and failure. This task is further complicated by the fact that there are currently so many EHRs in use within ophthalmology. For example, the AAO review website currently lists 30 different EHR products. These EHRs are not each appropriate for all practices, which again makes realistic comparisons difficult. A final challenge in our quest to understand the effect of EHRs on ophthalmology is that the completely electronic office is likely a collection of multiple information systems. These typically include systems for patient registration and schedARTICLE INFORMATION Author Affiliations: Glaucoma Center of Excellence, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, Maryland. Corresponding Author: Michael V. Boland, MD, PhD, Glaucoma Center of Excellence, Wilmer Eye Institute, Johns Hopkins University School of Medicine, 600 N Wolfe St, Wilmer 131, Baltimore, MD 21287 (boland @jhu.edu). Published Online: April 16, 2015. doi:10.1001/jamaophthalmol.2015.0913. Conflict of Interest Disclosures: None reported. REFERENCES 1. Centers for Medicare and Medicaid Services. EHR incentive program summary report. http://www.cms .gov/Regulations-and-Guidance/Legislation /EHRIncentivePrograms/Downloads/December2014
634
uling, clinical documentation (what we typically refer to as the EHR), charge capture and billing and, in the case of ophthalmology, the management of images and reports from inoffice testing. In a given practice, these systems may come from a single vendor or from 4 different vendors. In any case, they each contribute to a practice’s success or failure in different ways that we need to better understand. Based on the rates of EHR adoption cited earlier, it is clear that the EHR era has finally arrived for medicine in general and for ophthalmology in particular. As with most new technology, EHRs will undoubtedly be used for good and evil alike. Our challenge as a specialty is to figure out as quickly as we can how to maximize the former and minimize the latter.
_SummaryReport.pdf. Published 2014. Accessed February 15, 2015. 2. Furukawa MF, King J, Patel V, Hsiao CJ, Adler-Milstein J, Jha AK. Despite substantial progress In EHR adoption, health information exchange and patient engagement remain low in office settings. Health Aff (Millwood). 2014;33(9): 1672-1679. 3. Boland MV, Chiang MF, Lim MC, et al; American Academy of Ophthalmology Medical Information Technology Committee. Adoption of electronic health records and preparations for demonstrating meaningful use: an American Academy of Ophthalmology survey. Ophthalmology. 2013;120 (8):1702-1710. 4. Jamoom E, Beatty P, Bercovitz A, Woodwell D, Palso K, Rechtsteiner E. Physician adoption of electronic health record systems: United States, 2011. NCHS Data Brief. 2012;(98):1-8. 5. Singh RP, Bedi R, Li A, et al. The practice impact of electronic health record system implementation
within a large multispecialty ophthalmic practice [published online April 16, 2015]. JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2015.0457. 6. Chiang MF, Read-Brown S, Tu DC, et al. Evaluation of electronic health record implementation in ophthalmology at an academic medical center (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2013;111: 70-92. 7. Lim MC. Glaucoma and EHR: perfect together? Review of Ophthalmology website. http://www .reviewofophthalmology.com/issue_toc/i/1533/. Published 2011. Accessed February 15, 2015. 8. Pandit RR, Boland MV. The impact of an electronic health record transition on a glaucoma subspecialty practice. Ophthalmology. 2013;120(4): 753-760. 9. American Academy of Ophthalmology. Electronic health record system reviews. http://www.aao.org /community/EHR-reviews/index.cfm. Accessed February 15, 2015.
JAMA Ophthalmology June 2015 Volume 133, Number 6 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a Cornell University User on 09/08/2016
jamaophthalmology.com
EDITORIAL
Electronic Health Records and Ophthalmology A Work in Progress Michael V. Boland, MD, PhD
The Health Information Technology for Economic and Clinical Health Act adopted in 2009 was designed to increase the use of electronic health records (EHRs) by US health care professionals and hospitals via a system of incentive payRelated article page 668 ments. As of December 2014, almost 340 000 professionals received these payments via Medicare and almost 170 000 professionals received payments via Medicaid. These professionals received more than $10 billion in payments for EHR use.1 As intended, the Health Information Technology for Economic and Clinical Health Act has had a clear effect on the adoption of EHRs, with the most recent estimates showing almost 80% of US physicians using one.2 These incentive payments for the meaningful use of EHRs will end in 2016 and professionals who choose not to use an EHR will begin to experience penalties that may increase to 4% of payments from Medicare by 2018. Therefore, it is a reasonable time to determine where ophthalmology stands in terms of the adoption and effect of EHRs. Our most recent evidence regarding the adoption of EHRs is a survey of American Academy of Ophthalmology (AAO) practices conducted in 2011.3 Based on those responses, we would expect that approximately 80% of ophthalmology practices have an EHR by now. This number corresponds closely to the rates found for medicine overall in 2013.2 Within these overall rates of adoption, some significant differences are hidden in terms of what kinds of practices have made the change to an EHR. A report on the adoption of EHRs by the Centers for Disease Control and Prevention in 2012 found that practices with older physicians, smaller practices, practices owned by physicians, and surgical specialty practices were all less likely to have implemented an EHR.4 Similar differences were noted in the AAO survey mentioned earlier in which smaller practices, physician-owned practices, and ophthalmologyonly practices were all less likely to be using an EHR. Beyond these differences, the 2011 AAO survey found practices were less satisfied in a number of ways with their EHRs compared with those surveyed in 2006. However, the rate of adoption is only 1 aspect of EHRs and it is important for our specialty to determine the effect of EHRs on practices and patients. How is EHR adoption going in ophthalmology? I believe the answer is that it depends. By that I mean the experience of EHR use in ophthalmology varies from practice to practice (even with the same EHR product) and even from subspecialty to subspecialty in the same department at large institutions. I say this based both on anecdotes related to me as a member of the AAO medical informajamaophthalmology.com
tion technology committee and on a growing body of evidence in the literature. The work by Singh et al 5 in this month’s issue of JAMA Ophthalmology supports this view in that it reported an overall successful installation of an EHR while also demonstrating that some divisions within their department experienced increased patient volume and revenue and some saw declines. Other work in similar academic practices has also shown that it is possible for practices in those settings to be successful.6,7 Within my own department, we were able to show that an EHR transition altered the time spent on various activities in our glaucoma clinic but did not decrease productivity or alter patient satisfaction with their encounter.8 Outside of academic practices, we have a real lack of published evidence regarding the success or failure of EHRs. We have to rely on the kinds of stories that my fellow AAO medical information technology committee members and I hear on a regular basis. We have all been asked at one time or another, “which EHR should I buy?” or “I am unhappy with my current EHR. What do I do now?” Such questions are frequently coupled with a story of a failed EHR deployment, either on their part or on the part of a colleague. If we are being honest in our responses to these questions, we have to tell them as I suggested earlier that it depends. In this case, it probably depends on ill-defined attributes of each practice. Just as there is no single architectural plan for every ophthalmology practice’s physical environment, there is no single EHR that will work well for every practice or even every practice of similar size and specialization. How do we obtain the knowledge necessary to determine the success or failure of an EHR in ophthalmology and the factors that lead to that outcome? First, we need to define standard metrics by which we will assess the effect of an EHR on a practice, the physicians using it, and the patients whose health information is being collected and stored. Ideal metrics would be insensitive to changes in other factors such as the number of professionals in the practice across time and changes in reimbursement by health insurers. There are clearly ways these non-EHR factors could result in an EHR being blamed (or credited) for changes that would have occurred with or without the EHR. In addition to more consistent metrics, we also need a more systematic way to communicate those metrics with one another. One possible approach to this need is the online system the AAO has created for EHR users to evaluate their systems.9 Because many EHRs on the website have too few reviews, because they are not collected in a systematic way, (Reprinted) JAMA Ophthalmology June 2015 Volume 133, Number 6
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a Cornell University User on 09/08/2016
633
Opinion Editorial
and because the questions asked do not address the possible reasons for success or failure, the data currently available are not adequate to determine risk factors for success and failure. This task is further complicated by the fact that there are currently so many EHRs in use within ophthalmology. For example, the AAO review website currently lists 30 different EHR products. These EHRs are not each appropriate for all practices, which again makes realistic comparisons difficult. A final challenge in our quest to understand the effect of EHRs on ophthalmology is that the completely electronic office is likely a collection of multiple information systems. These typically include systems for patient registration and schedARTICLE INFORMATION Author Affiliations: Glaucoma Center of Excellence, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, Maryland. Corresponding Author: Michael V. Boland, MD, PhD, Glaucoma Center of Excellence, Wilmer Eye Institute, Johns Hopkins University School of Medicine, 600 N Wolfe St, Wilmer 131, Baltimore, MD 21287 (boland @jhu.edu). Published Online: April 16, 2015. doi:10.1001/jamaophthalmol.2015.0913. Conflict of Interest Disclosures: None reported. REFERENCES 1. Centers for Medicare and Medicaid Services. EHR incentive program summary report. http://www.cms .gov/Regulations-and-Guidance/Legislation /EHRIncentivePrograms/Downloads/December2014
634
uling, clinical documentation (what we typically refer to as the EHR), charge capture and billing and, in the case of ophthalmology, the management of images and reports from inoffice testing. In a given practice, these systems may come from a single vendor or from 4 different vendors. In any case, they each contribute to a practice’s success or failure in different ways that we need to better understand. Based on the rates of EHR adoption cited earlier, it is clear that the EHR era has finally arrived for medicine in general and for ophthalmology in particular. As with most new technology, EHRs will undoubtedly be used for good and evil alike. Our challenge as a specialty is to figure out as quickly as we can how to maximize the former and minimize the latter.
_SummaryReport.pdf. Published 2014. Accessed February 15, 2015. 2. Furukawa MF, King J, Patel V, Hsiao CJ, Adler-Milstein J, Jha AK. Despite substantial progress In EHR adoption, health information exchange and patient engagement remain low in office settings. Health Aff (Millwood). 2014;33(9): 1672-1679. 3. Boland MV, Chiang MF, Lim MC, et al; American Academy of Ophthalmology Medical Information Technology Committee. Adoption of electronic health records and preparations for demonstrating meaningful use: an American Academy of Ophthalmology survey. Ophthalmology. 2013;120 (8):1702-1710. 4. Jamoom E, Beatty P, Bercovitz A, Woodwell D, Palso K, Rechtsteiner E. Physician adoption of electronic health record systems: United States, 2011. NCHS Data Brief. 2012;(98):1-8. 5. Singh RP, Bedi R, Li A, et al. The practice impact of electronic health record system implementation
within a large multispecialty ophthalmic practice [published online April 16, 2015]. JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2015.0457. 6. Chiang MF, Read-Brown S, Tu DC, et al. Evaluation of electronic health record implementation in ophthalmology at an academic medical center (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2013;111: 70-92. 7. Lim MC. Glaucoma and EHR: perfect together? Review of Ophthalmology website. http://www .reviewofophthalmology.com/issue_toc/i/1533/. Published 2011. Accessed February 15, 2015. 8. Pandit RR, Boland MV. The impact of an electronic health record transition on a glaucoma subspecialty practice. Ophthalmology. 2013;120(4): 753-760. 9. American Academy of Ophthalmology. Electronic health record system reviews. http://www.aao.org /community/EHR-reviews/index.cfm. Accessed February 15, 2015.
JAMA Ophthalmology June 2015 Volume 133, Number 6 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a Cornell University User on 09/08/2016
jamaophthalmology.com
