Electronic health record impact on productivity and efficiency in an academic pediatric ophthalmology practice

Dr. Google vs. Dr. ChatGPT: Exploring the Use of Artificial Intelligence in Ophthalmology by Comparing the Accuracy, Safety, and Readability of Responses to Frequently Asked Patient Questions Regarding Cataracts and Cataract Surgery

PURPOSE

Patients are using online search modalities to learn about their eye health. While Google remains the most popular search engine, the use of large language models (LLMs) like ChatGPT has increased. Cataract surgery is the most common surgical procedure in the US, and there is limited data on the quality of online information that populates after searches related to cataract surgery on search engines such as Google and LLM platforms such as ChatGPT. We identified the most common patient frequently asked questions (FAQs) about cataracts and cataract surgery and evaluated the accuracy, safety, and readability of the answers to these questions provided by both Google and ChatGPT. We demonstrated the utility of ChatGPT in writing notes and creating patient education materials.

METHODS

The top 20 FAQs related to cataracts and cataract surgery were recorded from Google. Responses to the questions provided by Google and ChatGPT were evaluated by a panel of ophthalmologists for accuracy and safety. Evaluators were also asked to distinguish between Google and LLM chatbot answers. Five validated readability indices were used to assess the readability of responses. ChatGPT was instructed to generate operative notes, post-operative instructions, and customizable patient education materials according to specific readability criteria.

RESULTS

Responses to 20 patient FAQs generated by ChatGPT were significantly longer and written at a higher reading level than responses provided by Google (p < .001), with an average grade level of 14.8 (college level). Expert reviewers were correctly able to distinguish between a human-reviewed and chatbot generated response an average of 31% of the time. Google answers contained incorrect or inappropriate material 27% of the time, compared with 6% of LLM generated answers (p < .001). When expert reviewers were asked to compare the responses directly, chatbot responses were favored (66%).

CONCLUSIONS

When comparing the responses to patients' cataract FAQs provided by ChatGPT and Google, practicing ophthalmologists overwhelming preferred ChatGPT responses. LLM chatbot responses were less likely to contain inaccurate information. ChatGPT represents a viable information source for eye health for patients with higher health literacy. ChatGPT may also be used by ophthalmologists to create customizable patient education materials for patients with varying health literacy.

Value of Electronic Health Records Measured Using Financial and Clinical Outcomes: Quantitative Study

BACKGROUND

The Health Information Technology for Economic and Clinical Health Act of 2009 was legislated to reduce health care costs, improve quality, and increase patient safety. Providers and organizations were incentivized to exhibit meaningful use of certified electronic health record (EHR) systems in order to achieve this objective. EHR adoption is an expensive investment, given the resources and capital that are invested. Due to the cost of the investment, a return on the EHR adoption investment is expected.

OBJECTIVE

This study performed a value analysis of EHRs. The objective of this study was to investigate the relationship between EHR adoption levels and financial and clinical outcomes by combining both financial and clinical outcomes into one conceptual model.

METHODS

We examined the multivariate relationships between different levels of EHR adoption and financial and clinical outcomes, along with the time variant control variables, using moderation analysis with a longitudinal fixed effects model. Since it is unknown as to when hospitals begin experiencing improvements in financial outcomes, additional analysis was conducted using a 1- or 2-year lag for profit margin ratios.

RESULTS

A total of 5768 hospital-year observations were analyzed over the course of 4 years. According to the results of the moderation analysis, as the readmission rate increases by 1 unit, the effect of a 1-unit increase in EHR adoption level on the operating margin decreases by 5.38%. Hospitals with higher readmission payment adjustment factors have lower penalties.

CONCLUSIONS

This study fills the gap in the literature by evaluating individual relationships between EHR adoption levels and financial and clinical outcomes, in addition to evaluating the relationship between EHR adoption level and financial outcomes, with clinical outcomes as moderators. This study provided statistically significant evidence (P<.05), indicating that there is a relationship between EHR adoption level and operating margins when this relationship is moderated by readmission rates, meaning hospitals that have adopted EHRs could see a reduction in their readmission rates and an increase in operating margins. This finding could further be supported by evaluating more recent data to analyze whether hospitals increasing their level of EHR adoption would decrease readmission rates, resulting in an increase in operating margins. Hospitals would incur lower penalties as a result of improved readmission rates, which would contribute toward improved operating margins.

Use of Epic Electronic Health Record System for Health Care Research: Scoping Review

BACKGROUND

Electronic health records (EHRs) enable health data exchange across interconnected systems from varied settings. Epic is among the 5 leading EHR providers and is the most adopted EHR system across the globe. Despite its global reach, there is a gap in the literature detailing how EHR systems such as Epic have been used for health care research.

OBJECTIVE

The objective of this scoping review is to synthesize the available literature on use cases of the Epic EHR for research in various areas of clinical and health sciences.

METHODS

We used established scoping review methods and searched 9 major information repositories, including databases and gray literature sources. To categorize the research data, we developed detailed criteria for 5 major research domains to present the results.

RESULTS

We present a comprehensive picture of the method types in 5 research domains. A total of 4669 articles were screened by 2 independent reviewers at each stage, while 206 articles were abstracted. Most studies were from the United States, with a sharp increase in volume from the year 2015 onwards. Most articles focused on clinical care, health services research and clinical decision support. Among research designs, most studies used longitudinal designs, followed by interventional studies implemented at single sites in adult populations. Important facilitators and barriers to the use of Epic and EHRs in general were identified. Important lessons to the use of Epic and other EHRs for research purposes were also synthesized.

CONCLUSIONS

The Epic EHR provides a wide variety of functions that are helpful toward research in several domains, including clinical and population health, quality improvement, and the development of clinical decision support tools. As Epic is reported to be the most globally adopted EHR, researchers can take advantage of its various system features, including pooled data, integration of modules and developing decision support tools. Such research opportunities afforded by the system can contribute to improving quality of care, building health system efficiencies, and conducting population-level studies. Although this review is limited to the Epic EHR system, the larger lessons are generalizable to other EHRs.

An examination of large-scale electronic health records implementation in Primary Healthcare Centers in Saudi Arabia: a qualitative study

Introduction

Digital transformation has become a buzzword in almost every industry in the twenti first century. Healthcare is not an exception. In the healthcare industry, digital transformation includes the utilization of electronic health records (EHRs), telemedicine, health information exchange, mobile health, and other interactive platforms. The importance of digital transformation in healthcare cannot be overemphasized as it has proven to be critical in improving patient outcomes, making healthcare delivery more efficient, and reducing costs. The positive impact of electronic health records was noticed almost immediately in the field of primary healthcare. It has been suggested that implementing electronic health records will enhance the accessibility and the process of distribution of health records between authorized users. As part of Saudi vision 2030, all healthcare organizations in Saudi Arabia are going to shift to digital transformation.

Methods

This study follows a qualitative, semi-structure, face-to-face interview approach. The collected data were analyzed using NVivo V10 software. Inductive thematic analysis approach was used to analyse the collected data from the interviews.

Result

Seventeen project team members, from different positions and backgrounds were purposively chosen to be interviewed. Three main themes and 38 codes were generated from the analysis of transcripts. The informants describe the implementation of electronic health records in the PHCs based on two different experiences. The participants reported that a previous attempt failed due to inappropriate infrastructure, lack of technical support, and low level of user acceptance. Therefore, the policymakers adopted several steps to increase the level of success and avoid failure causes. They initially established well-defined requests for proposals followed by continuous commendation among the project team and conducted a consultation on multiple levels (country level; organizational level and individual level).

Conclusion

This study concluded that the main causes that lead to the failure of the large-scale project were lack of connectivity, lack of technical support, and staff changes, particularly those who occupied high-level positions in the Saudi ministry of Health. The success rate of EHRs implementation can be directly impacted by the size of the project. Large-scale projects are complicated and may be subject to numerous challenges compared with small projects. Significant factors such as training, support, legal issues, and organizational workflow and redesign were a concern of the project team during the pre-implementation phase. In addition, other factors related to technology and end-users were included in the EHRs implementation plan.

Development of an electronic medical record provider evaluation template for children with attention deficit hyperactivity disorder

ABSTRACT

Attention deficit hyperactivity disorder (ADHD) is the most common neurobehavioral condition in children. Current guidelines recommend that Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V) criteria be met before diagnosing ADHD. However, 14-49% of providers are not documenting the use of DSM-V criteria in screening and diagnosis. The use of a standardized electronic health record (EHR) ADHD template is a potential option to assist providers with documenting the DSM-V criteria. The aim for this project was to provide a 1-hour educational in-service on the use of the DSM-V criteria, Vanderbilt rating scale, and a revised EHR ADHD template, and to assess provider use pre and post intervention. Results showed that few providers (n = 1; 2%) document using DSM-V criteria preintervention and post intervention with only a modest increase in template use (n = 3; 5%). However, there were statistical differences between provider type with advanced practice registered nurses and physician assistants screening more frequently using the EHR DSM-V ADHD template compared with physicians (p = .009). Future studies are needed to evaluate barriers to use, including practice preference, openness to change, and other factors that may affect provider workflow.

Exploring facilitators of the implementation of electronic health records in Saudi Arabia

INTRODUCTION

The introduction of information technology was one of the key priorities for policy-makers in health care organisations over the last two decades due to the potential benefits of this technology to improve health care services and quality. However, approximately 50% of those projects failed to achieve their intended aims. This was a result of several factors, including the cost of these projects. The Saudi Ministry of Health (MoH) planned to implement an electronic health record system (EHRS) in approximately 2100 primary health care centres nationwide. It was acknowledged that this project may face hurdles, which might result in the failure of the project if implementation facilitators were not first determined. According to the Saudi MoH, previous electronic health record system implementation in primary health care centres failed as a consequence of several barriers, such as poor infrastructure, lack of connectivity and lack of interoperability. However, the facilitators of successful electronic health record system implementation in Saudi primary health care centres are not understood.

AIM

To determine the facilitators that enhance the success of the implementation of an EHRS in public primary health care centres in SA.

METHOD

A mixed methods approach was used with both qualitative and quantitative methods (qualitative using semistructured interviews and quantitative with a closed survey). The purpose of the utilisation of exploratory mixed methods was to identify a wide range of facilitators that may influence EHRS implementation. The data were obtained from two different perspectives, primary health care centre practitioners and project team members. A total of 351 practitioners from 21 primary health care centres participated in the online survey, and 14 key informants at the Saudi Ministry of Health who were directly involved in the electronic health record system implementation in the primary health care centres agreed to be interviewed face to face.

RESULTS

The findings from both studies revealed several facilitators. Among these facilitators, financial resources were found to be the most influential factor that assisted in overcoming some barriers, such as software selection. The size of the primary health care centres was the second facilitator of successful implementation, despite the scale of the project. Perceived usefulness was another facilitator identified in both the interviews and the survey. More than 90% of the participants thought that the electronic health record system was useful and could contribute to improving the quality of health care services. While a high level of satisfaction was expressed towards the electronic health record system's usability and efficiency, low levels of satisfaction were recorded for organisational factors such as user involvement, training and support. Hence, system usability and efficiency were documented to be other facilitators of successful electronic health record system implementation in Saudi primary health care centres.

CONCLUSION

The findings of the present study suggest that sufficient financial support is essential to enhance the success of electronic health record system implementation despite the scale of the project. Additionally, effective leadership and project management are core factors to overcome many obstacles and ensure the success of large-scale projects.

The Value of Electronic Health Records Since the Health Information Technology for Economic and Clinical Health Act: Systematic Review

Background

Electronic health records (EHRs) are the electronic records of patient health information created during ≥1 encounter in any health care setting. The Health Information Technology Act of 2009 has been a major driver of the adoption and implementation of EHRs in the United States. Given that the adoption of EHRs is a complex and expensive investment, a return on this investment is expected.

Objective

This literature review aims to focus on how the value of EHRs as an intervention is defined in relation to the elaboration of value into 2 different value outcome categories, financial and clinical outcomes, and to understand how EHRs contribute to these 2 value outcome categories.

Methods

This literature review was conducted using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). The initial search of key terms, EHRs, values, financial outcomes, and clinical outcomes in 3 different databases yielded 971 articles, of which, after removing 410 (42.2%) duplicates, 561 (57.8%) were incorporated in the title and abstract screening. During the title and abstract screening phase, articles were excluded from further review phases if they met any of the following criteria: not relevant to the outcomes of interest, not relevant to EHRs, nonempirical, and non–peer reviewed. After the application of the exclusion criteria, 80 studies remained for a full-text review. After evaluating the full text of the residual 80 studies, 26 (33%) studies were excluded as they did not address the impact of EHR adoption on the outcomes of interest. Furthermore, 4 additional studies were discovered through manual reference searches and were added to the total, resulting in 58 studies for analysis. A qualitative analysis tool, ATLAS.ti. (version 8.2), was used to categorize and code the final 58 studies.

Results

The findings from the literature review indicated a combination of positive and negative impacts of EHRs on financial and clinical outcomes. Of the 58 studies surveyed for this review of the literature, 5 (9%) reported on the intersection of financial and clinical outcomes. To investigate this intersection further, the category “Value–Intersection of Financial and Clinical Outcomes” was generated. Approximately 80% (4/5) of these studies specified a positive association between EHR adoption and financial and clinical outcomes.

Conclusions

This review of the literature reports on the individual and collective value of EHRs from a financial and clinical outcomes perspective. The collective perspective examined the intersection of financial and clinical outcomes, suggesting a reversal of the current understanding of how IT investments could generate improvements in productivity, and prompted a new question to be asked about whether an increase in productivity could potentially lead to more IT investments.

Acceptance and Perception of Artificial Intelligence Usability in Eye Care (APPRAISE) for Ophthalmologists: A Multinational Perspective

Background

Many artificial intelligence (AI) studies have focused on development of AI models, novel techniques, and reporting guidelines. However, little is understood about clinicians' perspectives of AI applications in medical fields including ophthalmology, particularly in light of recent regulatory guidelines. The aim for this study was to evaluate the perspectives of ophthalmologists regarding AI in 4 major eye conditions: diabetic retinopathy (DR), glaucoma, age-related macular degeneration (AMD) and cataract.

Methods

This was a multi-national survey of ophthalmologists between March 1st, 2020 to February 29th, 2021 disseminated via the major global ophthalmology societies. The survey was designed based on microsystem, mesosystem and macrosystem questions, and the software as a medical device (SaMD) regulatory framework chaired by the Food and Drug Administration (FDA). Factors associated with AI adoption for ophthalmology analyzed with multivariable logistic regression random forest machine learning.

Results

One thousand one hundred seventy-six ophthalmologists from 70 countries participated with a response rate ranging from 78.8 to 85.8% per question. Ophthalmologists were more willing to use AI as clinical assistive tools (88.1%, n = 890/1,010) especially those with over 20 years' experience (OR 3.70, 95% CI: 1.10-12.5, p = 0.035), as compared to clinical decision support tools (78.8%, n = 796/1,010) or diagnostic tools (64.5%, n = 651). A majority of Ophthalmologists felt that AI is most relevant to DR (78.2%), followed by glaucoma (70.7%), AMD (66.8%), and cataract (51.4%) detection. Many participants were confident their roles will not be replaced (68.2%, n = 632/927), and felt COVID-19 catalyzed willingness to adopt AI (80.9%, n = 750/927). Common barriers to implementation include medical liability from errors (72.5%, n = 672/927) whereas enablers include improving access (94.5%, n = 876/927). Machine learning modeling predicted acceptance from participant demographics with moderate to high accuracy, and area under the receiver operating curves of 0.63-0.83.

Conclusion

Ophthalmologists are receptive to adopting AI as assistive tools for DR, glaucoma, and AMD. Furthermore, ML is a useful method that can be applied to evaluate predictive factors on clinical qualitative questionnaires. This study outlines actionable insights for future research and facilitation interventions to drive adoption and operationalization of AI tools for Ophthalmology.

An electronic health record (EHR) log analysis shows limited clinician engagement with unsolicited genetic test results

How clinicians utilize medically actionable genomic information, displayed in the electronic health record (EHR), in medical decision-making remains unknown. Participating sites of the Electronic Medical Records and Genomics (eMERGE) Network have invested resources into EHR integration efforts to enable the display of genetic testing data across heterogeneous EHR systems. To assess clinicians’ engagement with unsolicited EHR-integrated genetic test results of eMERGE participants within a large tertiary care academic medical center, we analyzed automatically generated EHR access log data. We found that clinicians viewed only 1% of all the eMERGE genetic test results integrated in the EHR. Using a cluster analysis, we also identified different user traits associated with varying degrees of engagement with the EHR-integrated genomic data. These data contribute important empirical knowledge about clinicians limited and brief engagements with unsolicited EHR-integrated genetic test results of eMERGE participants. Appreciation for user-specific roles provide additional context for why certain users were more or less engaged with the unsolicited results. This study highlights opportunities to use EHR log data as a performance metric to more precisely inform ongoing EHR-integration efforts and decisions about the allocation of informatics resources in genomic research.

Effect of Scribes on Efficiency in Academic Ophthalmology Practice

Objective The aim of the study is to determine the effects of scribes on efficiency in an academic ophthalmology practice.

Design This is a quality improvement study conducted by two ophthalmologists at an academic ophthalmology practice at UT Health San Antonio from January 2018 to April 2018. Implementation of scribes in practice was the primary intervention. Session time, patient encounter time, and template time adherence were recorded pre- and post-intervention. A second retrospective arm of the study at the same institution was performed to evaluate long-term effects of scribes on efficiency in ophthalmology practice on session times and patient volume 12 to 18 months after intervention.

Main Outcome Measures Primary study outcomes and measures were the effect of scribes in academic ophthalmology practice on physician efficiency in terms of clinic session time, individual encounter time, and amount of patients seen per session, in addition to time adherence based on type of patient encounter.

Results Eighty-three patients and 17 half-day clinic sessions and 169 patients and 21 half-day clinic sessions were included in the preintervention and post-intervention datasets, respectively. Number of patients per session was approximately 15 and was kept similar pre- and post-intervention (p = 0.45). Mean preintervention session time was 265.0 ± 31.4 minutes, in contrast to 223.4 ± 19.9 minutes after intervention (p < 0.001). Mean preintervention patient encounter time was 15.0 ± 8.3 minutes, while the mean encounter time after intervention was 10.9 ± 7.0 minutes (p < 0.005). In a retrospective analysis of 20 clinic sessions and 438 patients 12 to 18 months after intervention, session time increased to 266.0 ± 22.0 minutes on average, but the average number of patients per session increased to 21.9 ± 2.8 minutes.

Conclusion Utilizing scribes in an ophthalmology practice can increase efficiency, allowing more patients to be seen or allowing time for other activities such as teaching or research.

Economic Value of Data and Analytics for Health Care Providers: Hermeneutic Systematic Literature Review

BACKGROUND

The benefits of data and analytics for health care systems and single providers is an increasingly investigated field in digital health literature. Electronic health records (EHR), for example, can improve quality of care. Emerging analytics tools based on artificial intelligence show the potential to assist physicians in day-to-day workflows. Yet, single health care providers also need information regarding the economic impact when deciding on potential adoption of these tools.

OBJECTIVE

This paper examines the question of whether data and analytics provide economic advantages or disadvantages for health care providers. The goal is to provide a comprehensive overview including a variety of technologies beyond computer-based patient records. Ultimately, findings are also intended to determine whether economic barriers for adoption by providers could exist.

METHODS

A systematic literature search of the PubMed and Google Scholar online databases was conducted, following the hermeneutic methodology that encourages iterative search and interpretation cycles. After applying inclusion and exclusion criteria to 165 initially identified studies, 50 were included for qualitative synthesis and topic-based clustering.

RESULTS

The review identified 5 major technology categories, namely EHRs (n=30), computerized clinical decision support (n=8), advanced analytics (n=5), business analytics (n=5), and telemedicine (n=2). Overall, 62% (31/50) of the reviewed studies indicated a positive economic impact for providers either via direct cost or revenue effects or via indirect efficiency or productivity improvements. When differentiating between categories, however, an ambiguous picture emerged for EHR, whereas analytics technologies like computerized clinical decision support and advanced analytics predominantly showed economic benefits.

CONCLUSIONS

The research question of whether data and analytics create economic benefits for health care providers cannot be answered uniformly. The results indicate ambiguous effects for EHRs, here representing data, and mainly positive effects for the significantly less studied analytics field. The mixed results regarding EHRs can create an economic barrier for adoption by providers. This barrier can translate into a bottleneck to positive economic effects of analytics technologies relying on EHR data. Ultimately, more research on economic effects of technologies other than EHRs is needed to generate a more reliable evidence base.

Factors Associated With Electronic Health Record Usage Among Primary Care Physicians After Hours: Retrospective Cohort Study

Background

There is limited published data on variation in physician usage of electronic health records (EHRs), particularly after hours. Research in this area could provide insight into the effects of EHR-related workload on physicians.

Objective

This study sought to examine factors associated with after-hours EHR usage among primary care physicians.

Methods

Electronic health records usage information was collected from primary care pediatricians in a large United States hospital. Inclusion criteria consisted solely of being a primary care physician who started employment with the hospital before the study period, so all eligible primary care physicians were included without sampling. Mixed effects statistical modeling was used to investigate the effects of age, gender, workload, normal-hour usage, week to week variation, and provider-to-provider variation on the after-hour usage of EHRs.

Results

There were a total of 3498 weekly records obtained on 50 physicians, of whom 22% were male and 78% were female. Overall, more EHR usage during normal work hours was associated with decreased usage after hours. The more work relative value units generated by physicians, the more time they spent interacting with EHRs after hours (β=.04, P<.001) and overall (ie, during normal hours and after hours) (β=.24, P<.001). Gender was associated with total usage time, with females spending more time than males (P=.03). However, this association was not observed with after-hours EHR usage. provider-to-provider variation was the largest and most dominant source of variation in after-hour EHR usage, which accounted for 52% of variance of total EHR usage.

Conclusion

The present study found that there is a considerable amount of variability in EHR use among primary care physicians, which suggested that many factors influence after-hours EHR usage by physicians. However, provider-to-provider variation was the largest and most dominant source of variation in after-hours EHR usage. While the results are intuitive, future studies should consider the effect of EHR use variations on workload efficiency.

A Pilot Study on the Effects of Physician Gaze on Patient Satisfaction in the Setting of Electronic Health Records

Purpose

To determine the amount of time ophthalmologists using Electronic Health Records (EHRs) spend looking at the patient and its correlation on patient satisfaction.

Methods

This prospective cohort study examined 67 patients seeking care at two different ophthalmology clinics. Videos of entire office visits were recorded and each video was graded for amount of time spent by physicians gazing at the patient, computer, paper medical records, or other areas. Videos were also graded for the amount of time examining the patient, and the physician speaking during each visit. A patient satisfaction survey was administered at the end of each office encounter. Time of physician gaze to the patient was correlated to satisfaction outcome measures.

Results

Ophthalmologists spent 28.0% ± 21.2% of the visit looking at the computer. Overall, patient satisfaction levels were very high (4.8 ± 0.5, 5-point Likert scale). Ophthalmologists spent the same amount of time looking at patients who were extremely satisfied (28.8% ± 16.7%) as those who were not extremely satisfied (28.8% ± 15.9%).

Conclusions

Ophthalmologists on EHRs spend over a third of each patient visit looking at the computer. However, patient satisfaction levels are very high. The amount of time that the ophthalmologist gazes at the patient or the computer does not appear to have an effect on patient satisfaction in this particular study. Further research still needs to be performed regarding the effects of EHRs on the patient experience. Physicians should continue to be sensitive to their patients' needs and approach the use of EHRs in patient encounters on an individual basis.

Evaluating New Ophthalmic Digital Devices for Safety and Effectiveness in the Context of Rapid Technological Development

Importance

The US Food and Drug Administration's medical device regulatory pathway was initially conceived with hardware devices in mind. The emerging market for ophthalmic digital devices necessitates an evolution of this paradigm.

Objectives

To facilitate innovation in ophthalmic digital health with attention to safety and effectiveness.

Evidence Review

This article presents a summary of the presentations, discussions, and literature review that occurred during a joint Ophthalmic Digital Health workshop of the American Academy of Ophthalmology, the American Academy of Pediatrics, the American Association for Pediatric Ophthalmology and Strabismus, the American Society of Cataract and Refractive Surgery, the American Society of Retina Specialists, the Byers Eye Institute at Stanford and the US Food and Drug Administration.

Findings

Criterion standards and expert graders are critically important in the evaluation of automated systems and telemedicine platforms. Training at all levels is important for the safe and effective operation of digital health devices. The risks associated with automation are substantially increased in rapidly progressive diseases. Cybersecurity and patient privacy warrant meticulous attention.

Conclusions and Relevance

With appropriate attention to safety and effectiveness, digital health technology could improve screening and treatment of ophthalmic diseases and improve access to care.

Diagnostic Accuracy of a Device for the Automated Detection of Diabetic Retinopathy in a Primary Care Setting

OBJECTIVE

To determine the diagnostic accuracy in a real-world primary care setting of a deep learning-enhanced device for automated detection of diabetic retinopathy (DR).

RESEARCH DESIGN AND METHODS

Retinal images of people with type 2 diabetes visiting a primary care screening program were graded by a hybrid deep learning-enhanced device (IDx-DR-EU-2.1; IDx, Amsterdam, the Netherlands), and its classification of retinopathy (vision-threatening [vt]DR, more than mild [mtm]DR, and mild or more [mom]DR) was compared with a reference standard. This reference standard consisted of grading according to the International Clinical Classification of DR by the Rotterdam Study reading center. We determined the diagnostic accuracy of the hybrid deep learning-enhanced device (IDx-DR-EU-2.1) against the reference standard.

RESULTS

A total of 1,616 people with type 2 diabetes were imaged. The hybrid deep learning-enhanced device's sensitivity/specificity against the reference standard was, respectively, for vtDR 100% (95% CI 77.1-100)/97.8% (95% CI 96.8-98.5) and for mtmDR 79.4% (95% CI 66.5-87.9)/93.8% (95% CI 92.1-94.9).

CONCLUSIONS

The hybrid deep learning-enhanced device had high diagnostic accuracy for the detection of both vtDR (although the number of vtDR cases was low) and mtmDR in a primary care setting against an independent reading center. This allows its' safe use in a primary care setting.

The use of Electronic Health Records to Support Population Health: A Systematic Review of the Literature

Electronic health records (EHRs) have emerged among health information technology as "meaningful use" to improve the quality and efficiency of healthcare, and health disparities in population health. In other instances, they have also shown lack of interoperability, functionality and many medical errors. With proper implementation and training, are electronic health records a viable source in managing population health? The primary objective of this systematic review is to assess the relationship of electronic health records' use on population health through the identification and analysis of facilitators and barriers to its adoption for this purpose. Authors searched Cumulative Index of Nursing and Allied Health Literature (CINAHL) and MEDLINE (PubMed), 10/02/2012-10/02/2017, core clinical/academic journals, MEDLINE full text, English only, human species and evaluated the articles that were germane to our research objective. Each article was analyzed by multiple reviewers. Group members recognized common facilitators and barriers associated with EHRs effect on population health. A final list of articles was selected by the group after three consensus meetings (n = 55). Among a total of 26 factors identified, 63% (147/232) of those were facilitators and 37% (85/232) barriers. About 70% of the facilitators consisted of productivity/efficiency in EHRs occurring 33 times, increased quality and data management each occurring 19 times, surveillance occurring 17 times, and preventative care occurring 15 times. About 70% of the barriers consisted of missing data occurring 24 times, no standards (interoperability) occurring 13 times, productivity loss occurring 12 times, and technology too complex occurring 10 times. The analysis identified more facilitators than barriers to the use of the EHR to support public health. Wider adoption of the EHR and more comprehensive standards for interoperability will only enhance the ability for the EHR to support this important area of surveillance and disease prevention. This review identifies more facilitators than barriers to using the EHR to support public health, which implies a certain level of usability and acceptance to use the EHR in this manner. The public-health industry should combine their efforts with the interoperability projects to make the EHR both fully adopted and fully interoperable. This will greatly increase the availability, accuracy, and comprehensiveness of data across the country, which will enhance benchmarking and disease surveillance/prevention capabilities.

Using EHR audit trail logs to analyze clinical workflow: A case study from community-based ambulatory clinics

To develop a workflow-supported clinical documentation system, it is a critical first step to understand clinical workflow. While Time and Motion studies has been regarded as the gold standard of workflow analysis, this method can be resource consuming and its data may be biased due to the cognitive limitation of human observers. In this study, we aimed to evaluate the feasibility and validity of using EHR audit trail logs to analyze clinical workflow. Specifically, we compared three known workflow changes from our previous study with the corresponding EHR audit trail logs of the study participants. The results showed that EHR audit trail logs can be a valid source for clinical workflow analysis, and can provide an objective view of clinicians' behaviors, multi-dimensional comparisons, and a highly extensible analysis framework.

Barriers to electronic medical record implementation: a comparison between ophthalmology and other surgical specialties in Canada

OBJECTIVE

In the present study, the barriers limiting widespread adoption of electronic medical records (EMRs) among Canadian ophthalmologists were evaluated in comparison with physicians from other surgical specialities. The published literature regarding EMR use in ophthalmic practice was also reviewed.

DESIGN

Population-based, cross-sectional study.

PARTICIPANTS

A total of 1199 Canadian surgeons participating in the 2014 National Physician Survey (NPS).

METHODS

Data regarding speciality surgeons' adoption of EMR programs were extracted from the 2014 NPS, a nationwide survey of practicing physicians in Canada. The data were entered into a spreadsheet, and basic statistical analyses, including χ² analyses, were performed to compare the responses of ophthalmologists to other surgeons.

RESULTS

Compared with other surgeons, ophthalmologists surveyed were significantly more likely to identify the following barriers to EMR adoption: "no suitable product for my practice" (p = 0.01), "too costly" (p = 0.0006), "too time consuming" (p < 0.0001), and "planning to retire soon" (p = 0.001). No statistically detectable differences were found between ophthalmologists and other surgeons for the following barriers: privacy concerns, reliability concerns, and lack of training.

CONCLUSIONS

The barriers that limit increased EMR adoption among Canadian ophthalmologists are different from those of other surgeons. This may be attributed to unique features of the field, including heavy reliance on hand-drawn figures in documentation, high patient volume, and the high costs associated with independent practice. Given the well-established benefits of EMR technology, consideration should be given to implementing strategies to mitigate these barriers. Additional research may help determine which specific improvements can be made to increase the use of EMR systems by ophthalmologists.

Leveraging Electronic Health Record Implementation to Facilitate Clinical and Operational Quality Improvement in an Ambulatory Surgical Clinic

The implementation of electronic health records is a challenging, complex process requiring significant resources. The temptation is to convert a paper process into electronic format. This strategy fosters a familiar product to the users but is fraught with pitfalls. We chose to utilize the opportunity of the implementation of an enterprise-wide ambulatory electronic health record to foster an overreaching clinical and operational improvement project in a multispecialty surgical ambulatory clinic practice. We interrogated every aspect of the practice: clinic design, scheduling, physical space, staffing, and clinical and operational workflows. We present here the results of a 3-year process improvement.

A Survey of the Literature on Unintended Consequences Associated with Health Information Technology: 2014-2015

OBJECTIVE

To summarize recent research on unintended consequences associated with implementation and use of health information technology (health IT). Included in the review are original empirical investigations published in English between 2014 and 2015 that reported unintended effects introduced by adoption of digital interventions. Our analysis focuses on the trends of this steam of research, areas in which unintended consequences have continued to be reported, and common themes that emerge from the findings of these studies.

METHOD

Most of the papers reviewed were retrieved by searching three literature databases: MEDLINE, Embase, and CINAHL. Two rounds of searches were performed: the first round used more restrictive search terms specific to unintended consequences; the second round lifted the restrictions to include more generic health IT evaluation studies. Each paper was independently screened by at least two authors; differences were resolved through consensus development.

RESULTS

The literature search identified 1,538 papers that were potentially relevant; 34 were deemed meeting our inclusion criteria after screening. Studies described in these 34 papers took place in a wide variety of care areas from emergency departments to ophthalmology clinics. Some papers reflected several previously unreported unintended consequences, such as staff attrition and patients' withholding of information due to privacy and security concerns. A majority of these studies (71%) were quantitative investigations based on analysis of objectively recorded data. Several of them employed longitudinal or time series designs to distinguish between unintended consequences that had only transient impact, versus those that had persisting impact. Most of these unintended consequences resulted in adverse outcomes, even though instances of beneficial impact were also noted. While care areas covered were heterogeneous, over half of the studies were conducted at academic medical centers or teaching hospitals.

CONCLUSION

Recent studies published in the past two years represent significant advancement of unintended consequences research by seeking to include more types of health IT applications and to quantify the impact using objectively recorded data and longitudinal or time series designs. However, more mixed-methods studies are needed to develop deeper insights into the observed unintended adverse outcomes, including their root causes and remedies. We also encourage future research to go beyond the paradigm of simply describing unintended consequences, and to develop and test solutions that can prevent or minimize their impact.

A Two-Year Longitudinal Assessment of Ophthalmologists' Perceptions after Implementing an Electronic Health Record System

OBJECTIVES

To understand the attitudes and perceptions of ophthalmologists toward an electronic health record (EHR) system, before and after its clinical implementation.

METHODS

Ophthalmologists at a single large academic ophthalmology department were surveyed longitudinally before and after implementation of a new EHR system. The survey measured ophthalmologists' attitudes toward implementation of a new EHR. Questions focused on satisfaction, efficiency, and documentation. All attending physicians (between 56 and 61 at various time points) in the University of Michigan Department of Ophthalmology and Visual Sciences were surveyed. We plotted positive responses to survey questions and assessed whether perceptions followed a J-curve with an initial decrease followed by an increase surpassing pre-implementation levels.

RESULTS

Survey responses were received from 32 (52%) ophthalmologists pre-implementation, and 28 (46%) at 3 months, 35 (57%) at 7 months, 40 (71%) at 13 months and 39 (67%) at 24 months post-implementation. After EHR implementation respondents were more likely to express concerns about their ability to create high-quality documentation (p<0.01) and the impact of an electronic health record on meaningful patient interaction (p<0.01). Physicians did not report a significant change in the amount of time spent documenting outside of regular clinical work hours (p=0.54) or on their clinic efficiency and workflow (p=0.97). There was no significant change in overall job satisfaction during the study period (p=0.69). We did not observe a J-curve for any of the survey responses analyzed.

CONCLUSIONS

As ophthalmology practices continue to transition to EHRs, adapting them to their specific culture and needs is important to maintain efficiency and user satisfaction. This study identifies areas of concern to ophthalmologists that may be addressed through education of physicians and customization of software as other practices move forward with EHR implementation.

The Impact of the Transition to an Electronic Medical Record on Patient Perceptions in a Pediatric Ophthalmology Practice

PURPOSE

To assess the impact of the transition from traditional paper-based medical records to electronic medical records in a pediatric ophthalmology practice at a tertiary care center.

METHODS

A prospective, cross-sectional survey was completed at three time points: 2 weeks prior to (phase 1), 2 weeks after (phase 2), and 3 months after (phase 3) the electronic medical record transition. The survey consisted of 10 Likert-type scaled questions assessing patient satisfaction and two free response questions estimating the wait time, which was completed by patients or parents/guardians whose child/children (younger than 18 years) had an appointment in the pediatric ophthalmology and strabismus clinic. Satisfaction scores and waiting times were compared within each phase and across phases and between different appointment types.

RESULTS

A total of 382 surveys were collected: 158 from phase 1, 68 from phase 2, and 156 from phase 3. Overall, patient satisfaction was high at all three time points. Patients' estimates of waiting time compared to actual waiting time were not significantly different at any phase; however, patients' estimates of time spent with the physician were significantly underestimated in phase 1 (20 vs 25 minutes, P = .04) and were correct or overestimated in phase 3.

CONCLUSIONS

Patients were satisfied with the service regardless of the use of paper charts or electronic medical records. The electronic medical record system does not seem to improve patients' waiting time, but has a significant impact on the perception of time spent with the physician. [J Pediatr Ophthalmol Strabismus. 2016;53(3):173-178.].

The effect of electronic health records adoption on patient visit volume at an academic ophthalmology department

BACKGROUND

Electronic health records (EHRs) have become a mandated part of delivering health care in the United States. The purpose of this study is to report patient volume before and after the transition to EHR in an academic outpatient ophthalmology practice.

METHODS

Review of patient visits per half-day and number of support staff for established faculty ophthalmologists between July and October for five consecutive years beginning the year before EHR implementation.

RESULTS

Eight physicians met inclusion criteria for the study. The number of patient visits was lower in each year after EHR adoption compared to baseline p ≤ 0.027). Patient volume per provider was reduced an average of 16.9% over the 4 years (range 15.3-18.5%), and during the final year studied, no provider had returned to the pre-EHR number of patients per clinic session. Support staffing was unchanged (p > 0.2).

CONCLUSIONS

Adoption of EHR was associated with a significantly reduced number of patient visits per clinic session in an academic setting in which support staffing remained stable. Maintaining clinic volume and access in similar settings may require use of additional staffing.

Variability in Electronic Health Record Usage and Perceptions among Specialty vs. Primary Care Physicians

Despite federal incentives for adoption of electronic health records (EHRs), surveys have shown that EHR use is less common among specialty physicians than generalists. Concerns have been raised that current-generation EHR systems are inadequate to meet the unique information gathering needs of specialists. This study sought to identify whether information gathering needs and EHR usage patterns are different between specialists and generalists, and if so, to characterize their precise nature. We found that specialists and generalists have significantly different perceptions of which elements of the EHR are most important and how well these systems are suited to displaying clinical information. Resolution of these disparities could have implications for clinical productivity and efficiency, patient and physician satisfaction, and the ability of clinical practices to achieve Meaningful Use incentives.