Association of the Presence of Trainees With Outpatient Appointment Times in an Ophthalmology Clinic.

Importance: Physicians face pressure to improve clinical efficiency, particularly with electronic health record (EHR) adoption and gradual shifts toward value-based reimbursement models. These pressures are especially pronounced in academic medical centers, where delivery of care must be balanced with medical education. However, the association of the presence of trainees with clinical efficiency in outpatient ophthalmology clinics is not known. Objective: To quantify the association of the presence of trainees (residents and fellows) and efficiency in an outpatient ophthalmology clinic. Design, Setting, and Participants: This single-center cohort study was conducted from January 1 through December 31, 2014, at an academic department of ophthalmology. Participants included 49 448 patient appointments with 33 attending physicians and 40 trainees. Exposures: Presence vs absence of trainees in an appointment or clinic session, as determined by review of the EHR audit log. Main Outcomes and Measures: Patient appointment time, as determined by time stamps in the EHR clinical data warehouse. Linear mixed models were developed to analyze variability among clinicians and patients. Results: Among the 33 study physicians (13 women [39%] and 20 men [61%]; median age, 44 years [interquartile range, 39-53 years]), appointments with trainees were significantly longer than appointments in clinic sessions without trainees (mean [SD], 105.0 [55.7] vs 80.3 [45.4] minutes; P < .001). The presence of a trainee in a clinic session was associated with longer mean appointment time, even in appointments for which the trainee was not present (mean [SD], 87.2 [49.2] vs 80.3 [45.4] minutes; P < .001). Among 33 study physicians, 3 (9%) had shorter mean appointment times when a trainee was present, 1 (3%) had no change, and 29 (88%) had longer mean appointment times when a trainee was present. Linear mixed models showed the presence of a resident was associated with a lengthening of appointment time of 17.0 minutes (95% CI, 15.6-18.5 minutes; P < .001), and the presence of a fellow was associated with a lengthening of appointment time of 13.5 minutes (95% CI, 12.3-14.8 minutes; P < .001). Conclusions and Relevance: Presence of trainees was associated with longer appointment times, even for patients not seen by a trainee. Although numerous limitations to this study design might affect the interpretation of the findings, these results highlight a potential challenge of maintaining clinical efficiency in academic medical centers and raise questions about physician reimbursement models.

Secondary use of electronic health record data for clinical workflow analysis.

Objective: Outpatient clinics lack guidance for tackling modern efficiency and productivity demands. Workflow studies require large amounts of timing data that are prohibitively expensive to collect through observation or tracking devices. Electronic health records (EHRs) contain a vast amount of timing data - timestamps collected during regular use - that can be mapped to workflow steps. This study validates using EHR timestamp data to predict outpatient ophthalmology clinic workflow timings at Oregon Health and Science University and demonstrates their usefulness in 3 different studies. Materials and Methods: Four outpatient ophthalmology clinics were observed to determine their workflows and to time each workflow step. EHR timestamps were mapped to the workflow steps and validated against the observed timings. Results: The EHR timestamp analysis produced times that were within 3 min of the observed times for >80% of the appointments. EHR use patterns affected the accuracy of using EHR timestamps to predict workflow times. Discussion: EHR timestamps provided a reasonable approximation of workflow and can be used for workflow studies. They can be used to create simulation models, analyze EHR use, and quantify the impact of trainees on workflow. Conclusion: The secondary use of EHR timestamp data is a valuable resource for clinical workflow studies. Sample timestamp data files and algorithms for processing them are provided and can be used as a template for more studies in other clinical specialties and settings.

Time Requirements for Electronic Health Record Use in an Academic Ophthalmology Center.

Importance: Electronic health record (EHR) systems have transformed the practice of medicine. However, physicians have raised concerns that EHR time requirements have negatively affected their productivity. Meanwhile, evolving approaches toward physician reimbursement will require additional documentation to measure quality and cost of care. To date, little quantitative analysis has rigorously studied these topics. Objective: To examine ophthalmologist time requirements for EHR use. Design, Setting, and Participants: A single-center cohort study was conducted between September 1, 2013, and December 31, 2016, among 27 stable departmental ophthalmologists (defined as attending ophthalmologists who worked at the study institution for ≥6 months before and after the study period). Ophthalmologists who did not have a standard clinical practice or who did not use the EHR were excluded. Exposures: Time stamps from the medical record and EHR audit log were analyzed to measure the length of time required by ophthalmologists for EHR use. Ophthalmologists underwent manual time-motion observation to measure the length of time spent directly with patients on the following 3 activities: EHR use, conversation, and examination. Main Outcomes and Measures: The study outcomes were time spent by ophthalmologists directly with patients on EHR use, conversation, and examination as well as total time required by ophthalmologists for EHR use. Results: Among the 27 ophthalmologists in this study (10 women and 17 men; mean [SD] age, 47.3 [10.7] years [median, 44; range, 34-73 years]) the mean (SD) total ophthalmologist examination time was 11.2 (6.3) minutes per patient, of which 3.0 (1.8) minutes (27% of the examination time) were spent on EHR use, 4.7 (4.2) minutes (42%) on conversation, and 3.5 (2.3) minutes (31%) on examination. Mean (SD) total ophthalmologist time spent using the EHR was 10.8 (5.0) minutes per encounter (range, 5.8-28.6 minutes). The typical ophthalmologist spent 3.7 hours using the EHR for a full day of clinic: 2.1 hours during examinations and 1.6 hours outside the clinic session. Linear mixed effects models showed a positive association between EHR use and billing level and a negative association between EHR use per encounter and clinic volume. Each additional encounter per clinic was associated with a decrease of 1.7 minutes (95% CI, -4.3 to 1.0) of EHR use time per encounter for ophthalmologists with high mean billing levels (adjusted R2 = 0.42; P = .01). Conclusions and Relevance: Ophthalmologists have limited time with patients during office visits, and EHR use requires a substantial portion of that time. There is variability in EHR use patterns among ophthalmologists.

Evaluating and Improving an Outpatient Clinic Scheduling Template Using Secondary Electronic Health Record Data.

Improving the efficiency of outpatient clinics is challenging in the face of increased patient loads, decreased reimbursements and potential negative productivity impacts of using electronic health records (EHR). We modeled outpatient ophthalmology clinic workflow using discrete event simulation for testing new scheduling templates that decrease patient wait time and improve clinic efficiency. Despite challenges in implementing the new scheduling templates in one outpatient clinic, the new templates improved patient wait time and clinic session length when they were followed. Analyzing EHR data about these schedules and their adherence to the template provides insight into new policies that can better balance the competing priorities of filling the schedules, meeting patient demand and minimizing wait time.

Clinic Workflow Simulations using Secondary EHR Data.

Clinicians today face increased patient loads, decreased reimbursements and potential negative productivity impacts of using electronic health records (EHR), but have little guidance on how to improve clinic efficiency. Discrete event simulation models are powerful tools for evaluating clinical workflow and improving efficiency, particularly when they are built from secondary EHR timing data. The purpose of this study is to demonstrate that these simulation models can be used for resource allocation decision making as well as for evaluating novel scheduling strategies in outpatient ophthalmology clinics. Key findings from this study are that: 1) secondary use of EHR timestamp data in simulation models represents clinic workflow, 2) simulations provide insight into the best allocation of resources in a clinic, 3) simulations provide critical information for schedule creation and decision making by clinic managers, and 4) simulation models built from EHR data are potentially generalizable.

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

PURPOSE: To measure the effect of electronic health record (EHR) implementation on productivity and efficiency in the pediatric ophthalmology division at an academic medical center. METHODS: Four established providers were selected from the pediatric ophthalmology division at the Oregon Health & Science University Casey Eye Institute. Clinical volume was compared before and after EHR implementation for each provider. Time elapsed from chart open to completion (OTC time) and the proportion of charts completed during business hours were monitored for 3 years following implementation. RESULTS: Overall there was an 11% decrease in clinical volume following EHR implementation, which was not statistically significant (P = 0.18). The mean OTC time ranged from 5.5 to 28.3 hours among providers in this study, and trends over time were variable among the four providers. Forty-four percent of all charts were closed outside normal business hours (30% on weekdays, 14% on weekends). CONCLUSIONS: EHR implementation was associated with a negative impact on productivity and efficiency in our pediatric ophthalmology division.

Impact of an electronic health record operating room management system in ophthalmology on documentation time, surgical volume, and staffing.

IMPORTANCE: Although electronic health record (EHR) systems have potential benefits, such as improved safety and quality of care, most ophthalmology practices in the United States have not adopted these systems. Concerns persist regarding potential negative impacts on clinical workflow. In particular, the impact of EHR operating room (OR) management systems on clinical efficiency in the ophthalmic surgery setting is unknown. OBJECTIVE: To determine the impact of an EHR OR management system on intraoperative nursing documentation time, surgical volume, and staffing requirements. DESIGN, SETTING, AND PARTICIPANTS: For documentation time and circulating nurses per procedure, a prospective cohort design was used between January 10, 2012, and January 10, 2013. For surgical volume and overall staffing requirements, a case series design was used between January 29, 2011, and January 28, 2013. This study involved ophthalmic OR nurses (n = 13) and surgeons (n = 25) at an academic medical center. EXPOSURES: Electronic health record OR management system implementation. MAIN OUTCOMES AND MEASURES: (1) Documentation time (percentage of operating time documenting [POTD], absolute documentation time in minutes), (2) surgical volume (procedures/time), and (3) staffing requirements (full-time equivalents, circulating nurses/procedure). Outcomes were measured during a baseline period when paper documentation was used and during the early (first 3 months) and late (4-12 months) periods after EHR implementation. RESULTS: There was a worsening in total POTD in the early EHR period (83%) vs paper baseline (41%) (P < .001). This improved to baseline levels by the late EHR period (46%, P = .28), although POTD in the cataract group remained worse than at baseline (64%, P < .001). There was a worsening in absolute mean documentation time in the early EHR period (16.7 minutes) vs paper baseline (7.5 minutes) (P < .001). This improved in the late EHR period (9.2 minutes) but remained worse than in the paper baseline (P < .001). While cataract procedures required more circulating nurses in the early EHR (mean, 1.9 nurses/procedure) and late EHR (mean, 1.5 nurses/procedure) periods than in the paper baseline (mean, 1.0 nurses/procedure) (P < .001), overall staffing requirements and surgical volume were not significantly different between the periods. CONCLUSIONS AND RELEVANCE: Electronic health record OR management system implementation was associated with worsening of intraoperative nursing documentation time especially in shorter procedures. However, it is possible to implement an EHR OR management system without serious negative impacts on surgical volume and staffing requirements.

Evaluation of electronic health record implementation in ophthalmology at an academic medical center (an American Ophthalmological Society thesis).

PURPOSE: To evaluate three measures related to electronic health record (EHR) implementation: clinical volume, time requirements, and nature of clinical documentation. Comparison is made to baseline paper documentation. METHODS: An academic ophthalmology department implemented an EHR in 2006. A study population was defined of faculty providers who worked the 5 months before and after implementation. Clinical volumes, as well as time length for each patient encounter, were collected from the EHR reporting system. To directly compare time requirements, two faculty providers who utilized both paper and EHR systems completed time-motion logs to record the number of patients, clinic time, and nonclinic time to complete documentation. Faculty providers and databases were queried to identify patient records containing both paper and EHR notes, from which three cases were identified to illustrate representative documentation differences. RESULTS: Twenty-three faculty providers completed 120,490 clinical encounters during a 3-year study period. Compared to baseline clinical volume from 3 months pre-implementation, the post-implementation volume was 88% in quarter 1, 93% in year 1, 97% in year 2, and 97% in year 3. Among all encounters, 75% were completed within 1.7 days after beginning documentation. The mean total time per patient was 6.8 minutes longer with EHR than paper (P<.01). EHR documentation involved greater reliance on textual interpretation of clinical findings, whereas paper notes used more graphical representations, and EHR notes were longer and included automatically generated text. CONCLUSION: This EHR implementation was associated with increased documentation time, little or no increase in clinical volume, and changes in the nature of ophthalmic documentation.

Electronic health record systems in ophthalmology: impact on clinical documentation.

OBJECTIVE: To evaluate quantitative and qualitative differences in documentation of the ophthalmic examination between paper and electronic health record (EHR) systems. DESIGN: Comparative case series. PARTICIPANTS: One hundred fifty consecutive pairs of matched paper and EHR notes, documented by 3 attending ophthalmologist providers. METHODS: An academic ophthalmology department implemented an EHR system in 2006. Database queries were performed to identify cases in which the same problems were documented by the same provider on different dates, using paper versus EHR methods. This was done for 50 consecutive pairs of examinations in 3 different diseases: age-related macular degeneration (AMD), glaucoma, and pigmented choroidal lesions (PCLs). Quantitative measures were used to compare completeness of documenting the complete ophthalmologic examination, as well as disease-specific critical findings using paper versus an EHR system. Qualitative differences in paper versus EHR documentation were illustrated by selecting representative paired examples. MAIN OUTCOME MEASURES: (1) Documentation score, defined as the number of examination elements recorded for the slit-lamp examination, fundus examination, and complete ophthalmologic examination and for critical clinical findings for each disease. (2) Paired comparison of qualitative differences in paper versus EHR documentation. RESULTS: For all 3 diseases (AMD, glaucoma, PCL), the number of complete examination findings recorded was significantly lower with paper than the EHR system (P ≤ 0.004). Among the 3 individual examination sections (general, slit lamp, fundus) for the 3 diseases, 5 of the 9 possible combinations had significantly lower mean documentation scores with paper than EHR notes. For 2 of the 3 diseases, the number of critical clinical findings recorded was significantly lower using paper versus EHR notes (P ≤ 0.022). All (150/150) paper notes relied on graphical representations using annotated hand-drawn sketches, whereas no (0/150) EHR notes contained drawings. Instead, the EHR systems documented clinical findings using textual descriptions and interpretations. CONCLUSIONS: There were quantitative and qualitative differences in the nature of paper versus EHR documentation of ophthalmic findings in this study. The EHR notes included more complete documentation of examination elements using structured textual descriptions and interpretations, whereas paper notes used graphical representations of findings. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Time-motion analysis of clinical nursing documentation during implementation of an electronic operating room management system for ophthalmic surgery.

Efficiency and quality of documentation are critical in surgical settings because operating rooms are a major source of revenue, and because adverse events may have enormous consequences. Electronic health records (EHRs) have potential to impact surgical volume, quality, and documentation time. Ophthalmology is an ideal domain to examine these issues because procedures are high-throughput and demand efficient documentation. This time-motion study examines nursing documentation during implementation of an EHR operating room management system in an ophthalmology department. Key findings are: (1) EHR nursing documentation time was significantly worse during early implementation, but improved to a level near but slightly worse than paper baseline, (2) Mean documentation time varied significantly among nurses during early implementation, and (3) There was no decrease in operating room turnover time or surgical volume after implementation. These findings have important implications for ambulatory surgery departments planning EHR implementation, and for research in system design.