More Ophthalmologists Using EHRs, but Say Productivity Is Down

Tara Haelle

December 29, 2017

Use of electronic health records (EHRs) has more than doubled among US ophthalmologists in the last decade, yet most of these physicians perceive EHRs as decreasing their productivity and increasing office costs, according to a cross-sectional survey study published online December 28 in JAMA Ophthalmology.

"The adoption rate for ophthalmologists in our survey (72.1%) was in line with that of other specialties," report Michele C. Lim, MD, from the University of California, Davis, in Sacramento, and colleagues.

The researchers emailed surveys to 2000 ophthalmologists out of more than 18,000 active US members of the American Academy of Ophthalmology in 2015 to 2016. A random selection from mailing address Zip codes generated the sample, and survey responses remained anonymous. "This sampling process was intended to provide a geographically diverse population of ophthalmologists while minimizing the opportunity for multiple responses from physicians who practiced within the same group," the authors explain in their article.

The survey asked ophthalmologists whether they had started using EHRs, how they perceived their financial and clinical productivity before and after EHR adoption, and their interaction with Medicare and Medicaid programs with perks for those who use EHRs.

Among the 348 (17.4%) ophthalmologists who completed the survey, 72.1% had adopted EHRs in their practice. The proportion of ophthalmologists who reported adoption of EHRs in similar previous surveys was 19% of 592 respondents in 2006 and 47% of 492 respondents in 2011.

Most respondents worked in physician-owned practices devoted solely to ophthalmology, with an average 22 years of practice and an average 5.3 years of EHR use. Nearly all had previously used paper records, and 88% of those currently using EHRs were present for the transition from paper records.

Just more than half the respondents (52%) hosted their EHR data at or near their practice, whereas 34% used a cloud-based server. One in 10 of those using EHRs did not know where the data were stored.

The mean number of ophthalmologists in a practice was higher among those with an EHR than without. "[O]phthalmologists from practices that were part of an integrated health system, government health system, or university were more likely to have adopted EHR than not," the authors report.

Ophthalmologists reported a variety of methods to view in-office test results, but paper reports still dominated, with 46% usage. However, 37% viewed images in the EHR, and 39% used vendor software, followed by scanned printed images and picture archiving and communication systems. (Offices could report multiple methods.)

Half the respondents (50%) reported satisfaction with their practice's clinical documentation system, and 49% were satisfied with their image management system.

Despite the increase in adoption, more physicians today than in the past perceived EHRs as having a negative effect on their productivity and financial bottom line. More than half of respondents in 2016 believed their productivity, as measured in patients seen per day, had decreased since adopting EHRs compared with less than 20% in 2006, when more than 60% saw an increase in productivity after EHR implementation.

Despite these concerns, three previous studies of academic ophthalmology practices found no change in patient volume after EHR adoption, Dr Lim and colleagues note, and only one smaller past study saw a decline. "The perception of productivity decline may be partially owing to the multiple tasks that are required to obtain incentive payments," the authors write.

A much higher proportion of physicians today also reported increases in overall post-EHR practice costs than in 2006 and 2011. More than 70% perceived an increase in the more recent survey compared with 40% in 2011 and less than 15% in 2006.

When asked about the effect of EHRs on revenue, the answers were less consistent. Thirty-five percent of respondents said it had remained the same since EHR adoption, 41% perceived a decrease, and almost 9% felt there had been an increase.

Meanwhile, a quarter of respondents believed EHR use made it easier to provide quality care compared with 35% who thought it was harder and 36% who saw no difference.

Respondents did perceive positive attitudes toward EHRs among their patients: 76% thought their patients felt mostly positive or neutral toward EHR use. Yet, when asked if they would return to paper records if given the opportunity, 36% of ophthalmologists said they would.

When the survey asked about federal Medicaid and Medicare programs that incentivize use of EHRs, 63% of respondents felt they knew enough about the program to decide whether to participate, but 11% had little or no knowledge.

"Among all respondents, 60% (n = 209) had already attested to stage 1 of the incentive program, 7.5% (n = 26) were planning to, 21% (n = 73) were not planning to, and 12% (n = 42) were unsure," the authors write. Leading reasons for not attesting to stage 1 included the cost of participation, the complexity of participation, and perceiving the incentive as irrelevant to their practice. Similar reasons were cited for not attesting to stage 2, although 41% had already done so and 42% planned to.

The authors note that the sample size was relatively small, and the low response rate suggests the findings may not represent the attitudes and beliefs of ophthalmologists nationwide.

"[I]t is possible that those who responded to the survey were more likely to have negative opinions of the EHR or that early, more enthusiastic adopters were more likely to have been included in the 2006 EHR survey and that this may account for the shift in opinions," Dr Lim and colleagues write. They also note that they did not collect financial data from practices, so responses related to finances are based only on physicians' perceptions.

Echoing that point, Jennifer S. Weizer, MD, and colleagues from the University of Michigan's Kellogg Eye Center in Ann Arbor, note in an accompanying commentary that the negative perceptions reported in this survey may result from selection bias and may not match up with available qualitative data.

"It would be interesting to determine whether the use of scribes was associated with a higher or lower rate of satisfaction with EHRs," they write.

The commentary authors also point to the 53% of respondents who saw net positive value in keeping EHRs despite the 68% who saw paper documentation as faster. "It is this value proposition that may likely underlie the future of EHR implementation and physician perceptions about EHR systems," Dr Weizer and colleagues write. "At its root, the Lim et al study illustrates the significant opportunities to create a better, more cohesive EHR system that includes integrated clinical and image documentation."

The research was funded by the American Academy of Ophthalmology. One coauthor reported unpaid work on the Scientific Advisory Board for Clarity Medical Systems and being a steering committee consultant for RAINBOW study at Novartis. Another coauthor has received research support from Alcon Labs.

JAMA Ophthalmol. Published online December 28, 2017. Article full text, Commentary extract

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