Should You Get an EHR or Wait?

Neil Chesanow

April 05, 2013

Ophthalmologists Haven't Jumped on the EHR Bandwagon

If you've been reluctant to invest in an electronic health record (EHR), you're not alone. According to the Centers for Disease Control and Prevention, among all physicians, only psychiatrists have been slower to adopt EHRs than ophthalmologists -- less than 30% of whom use one.^[1] (Cardiologists, in contrast, have the highest adoption rate: approximately 70%.)

A 2013 survey of 17,000 doctors by Black Book Rankings found that up to 17% of practices with an EHR are considering switching products by the end of the year.^[2] Among discontented users, ophthalmologists rank near the top.

Nor are EHR users shy about venting their frustrations. Internet chat rooms and forums, journal articles, and personal anecdotes catalog a sea of complaints, ranging from systems so slow that they impede patient flow, to the multitudinous, time-eating clicks required to perform even the simplest tasks and the migraine-inducing barrage of drug/drug interaction alerts.

The general-purpose EHRs designed for any specialty that are now available with ophthalmology-specific modules fall so far short in meeting the unique needs of ophthalmologists that in 2011, the American Academy of Ophthalmology felt compelled to issue a special report aimed at both potential purchasers and at EHR vendors, detailing the specific requirements for EHRs in ophthalmology.^[3]

Long on Glitches, Short on Functionality

But even ophthalmology-specific EHRs are often not ready for prime time, in the opinion of some users. Consider, for example, Roger F. Steinert, MD, Chair of Ophthalmology and Director of the Gavin Herbert Eye Institute at the University of California, Irvine. His institute uses a leading EHR specifically designed for ophthalmologists. It has functional limitations and glitches galore.

Integrating a private practice EHR into a university setting with many connectivity and compliance issues is a particular stress test. "In some ways, these experiences are good overall, because they force growth," Steinert says. "We have the benefit of a vendor that wants to please us and a large IT department. But even in that setting, we have challenges that continue."

"Right now our experience has been more negative than positive," Steinert confesses. Encounter forms are so problematic that institute providers have been forced to use paper forms for fear of losing charges, he says. On the positive side, he feels that they have absorbed all of the negative "punches" and that going forward, most changes will be positive.

But at this point, many of his expectations for EHR performance have yet to be realized. Customizable templates? Forget it. "Even though there are buttons that say 'cataract post-ophthalmology' and 'refractive surgery,' the screens are very abbreviated and wouldn't meet compliance requirements, and we wouldn't feel comfortable that we were documenting properly," he says. "So they're useless."

EHR inefficiency is an especially sore point with ophthalmologists, who need to work quickly. Using the EHR "adds 5 minutes to every one of my examinations," says Steinert. "That's a lot of time." As for e-prescribing, "even if you're really quick, it can chew up at least 1-2 minutes just getting a prescription transferred to a pharmacy. And God help you if the patient says, 'Oh, I don't want it to go to CVS. I'd rather have it go to Costco.' That wastes another 1-2 minutes."

As for the hand-drawn sketches of the patient's condition that ophthalmologists routinely add to the patient record, the digital version "looks like a 3-year-old did them. You're using a mouse. They really stink," Steinert says.

Having to reenter his username and password every 10 minutes for security reasons was another time-consuming nuisance for Steinert. Now, institute providers swipe computerized ID badges to log back into the EHR, which eliminates typing, "but it's still not instantaneous," Steinert says. "It takes 10-15 seconds for the computer to wake up and get oriented."

Steinert has learned to use that interlude to greet a patient, so precious time isn't wasted, because everything takes either a little bit or a lot longer to do now that things are automated. "It's just the reality of where we are right now," he says.