Ophthalmologists Spend Substantial Time on EHR Use

Tara Haelle

October 17, 2017

Ophthalmologists spent more than a quarter of their time with patients on electronic health records (EHRs), despite already having limited time overall to spend with patients, according to a single-center cohort study published October 12 in JAMA Ophthalmology.

"Physicians face growing time pressures as care of chronic medical issues becomes more complex and as increasing emphasis is placed on reporting patient satisfaction and quality of care metrics," write Sarah Read-Brown, BA, and colleagues from Oregon Health & Science University in Portland. "These time pressures may have negative consequences for patients, as research suggests that physician performance suffers under time pressure."

They add, "[T]hese findings highlight the importance of developing EHRs to meet the needs of patients and physicians and to develop appropriate training programs to improve the quality and efficiency of care."

The researchers analyzed medical record and EHR audit log time stamps for 27 ophthalmologists from September 2013 through December 2016. All the ophthalmologists had worked at Oregon Health & Science University's Casey Eye Institute for at least 6 months before and after the study period, had a standard clinical practice, and used EHR.

The researchers also directly observed five ophthalmologists during at least five half-day clinic sessions to measure how much time they spent with patients on EHR use, conversation, and examination. The ophthalmologists came from five different subspecialties: comprehensive, cornea, glaucoma, pediatrics, and retina.

Among the 27 ophthalmologists, 10 were women, 17 were men, and their average age was 47.3 years. The ophthalmologists spent an average 11.2 minutes with patients, which broke down into a mean 3 minutes (27%) on EHR, 4.7 minutes (42%) on conversation and 3.5 minutes (31%) on examination. The ophthalmologists spent an average total of 10.8 minutes on EHR per patient encounter, ranging from 5.8 to 28.6 minutes.

Across a typical full clinical work day, ophthalmologists used the EHR for 3.7 hours, including 2.1 hours during patient encounters and 1.6 hours outside clinical encounters. Removing two physicians from the analysis who were outliers in terms of their time spent with patients did not significantly change average time spent using EHR.

The researchers did not design the study to analyze quality of care or patient outcomes, but they expressed concern about the potential effects of EHR use.

"Although EHRs have enormous potential to improve quality of care, they also create clerical and cognitive burdens, bloated records with copied and pasted text, and frequent interruptions that threaten the potentially beneficial outcomes," the authors write. "Several surveys have shown a correlation between EHR use and physician burnout due to EHR-related stress and significant EHR time spent outside traditional work hours."

The authors also reported variation among the ophthalmologists studied.

"In general, higher clinic volumes are associated with less EHR time per encounter and more total EHR time," they report. "Billing level, a reflection of the complexity of the patient encounter and documentation, also affects the variability of EHR use among ophthalmologists." Ophthalmologists with higher average billing levels spent 1.7 fewer minutes on EHR per patient with each additional clinical encounter they had.

"Ophthalmologists with medium and high mean billing levels had lower clinic volumes and their EHR use was the most affected by changes in clinic volume," the authors report. "Ophthalmologists with low mean billing levels saw the most patients, displayed a wide variety of clinic volumes, and were not affected by the influence of clinic volume on EHR use."

In an invited commentary, Michael V. Boland, MD, PhD, from the Johns Hopkins University School of Medicine Wilmer Eye Institute in Baltimore, Maryland, noted the need to determine how information systems can best be used to support patient care.

"One important aspect of EHRs in this regard is the degree to which they do or do not support efficiency in typically busy ophthalmology practices," he writes. However, the study findings do not provide the context needed to know whether the time ophthalmologists spent on EHRs was too much, too little, or just right. It is difficult to compare ophthalmologists' time on EHRs with that of physicians in other specialties, and it would be helpful to know what specific tasks physicians are doing during EHR use.

"It will then be possible to make value judgments about the importance of each task — is each worth the time spent?" he writes. "We might be willing to experience increased documentation time if the documentation that is produced is readable and available to colleagues before, during, and after clinical encounters, for example."

Dr Boland also recommends more research into physicians' subjective experiences with their particular EHR systems. He recommends additional analysis of EHR use and time spent on specific EHR tasks at large hospitals and healthcare systems as well as smaller practices where experiences and needs may differ.

"[I]nformation technology has transformed much of our lives outside of medicine and has the potential to do the same for patient care," Dr Boland writes. "One of the reasons information technology has been slow to come to health care, I believe, is that the data that clinicians review, collect, and communicate are significantly more complicated than just about any other industry."

It is therefore time, he concludes, to determine how best to use EHR systems to provide the most efficient and highest-quality patient care.

The research was funded by the National Institutes of Health and Research to Prevent Blindness. Dr Chiang reports consulting for Novartis and served unpaid as a Scientific Advisory Board member for Clarity Medical Systems.

JAMA Ophthalmol. Published October 12, 2017. Article full text, Commentary extract

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