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Appl Clin Inform 2020; 11(01): 130-141
DOI: 10.1055/s-0040-1701255
Research Article
Georg Thieme Verlag KG Stuttgart · New York

Promoting Quality Face-to-Face Communication during Ophthalmology Encounters in the Electronic Health Record Era

Sally L. Baxter
1   Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, United States
2   Health Sciences Department of Biomedical Informatics, University of California San Diego, La Jolla, California, United States
,
Helena E. Gali
1   Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, United States
2   Health Sciences Department of Biomedical Informatics, University of California San Diego, La Jolla, California, United States
,
Michael F. Chiang
3   Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States
4   Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, Oregon, United States
,
Michelle R. Hribar
3   Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States
4   Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, Oregon, United States
,
Lucila Ohno-Machado
2   Health Sciences Department of Biomedical Informatics, University of California San Diego, La Jolla, California, United States
5   Division of Health Services Research and Development, Veterans Administration San Diego Healthcare System, San Diego, California, United States
,
Robert El-Kareh
2   Health Sciences Department of Biomedical Informatics, University of California San Diego, La Jolla, California, United States
,
Abigail E. Huang
3   Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States
,
Heather E. Chen
1   Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, United States
,
Andrew S. Camp
1   Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, United States
,
Don O. Kikkawa
1   Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, United States
,
Bobby S. Korn
1   Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, United States
,
Jeffrey E. Lee
1   Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, United States
,
Christopher A. Longhurst
2   Health Sciences Department of Biomedical Informatics, University of California San Diego, La Jolla, California, United States
,
Marlene Millen
2   Health Sciences Department of Biomedical Informatics, University of California San Diego, La Jolla, California, United States
› Author Affiliations Funding This study was supported by the Heed Ophthalmic Foundation, National Institutes of Health (P30EY022589, P30EY10572, R00LM12238, T15LM011271, and UL RR031980), and Research to Prevent Blindness.
Further Information

Publication History

06 November 2019

24 December 2019

Publication Date:
19 February 2020 (online)

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Abstract

Objective To evaluate informatics-enabled quality improvement (QI) strategies for promoting time spent on face-to-face communication between ophthalmologists and patients.

Methods This prospective study involved deploying QI strategies during implementation of an enterprise-wide vendor electronic health record (EHR) in an outpatient academic ophthalmology department. Strategies included developing single sign-on capabilities, activating mobile- and tablet-based applications, EHR personalization training, creating novel workflows for team-based orders, and promoting problem-based charting to reduce documentation burden. Timing data were collected during 648 outpatient encounters. Outcomes included total time spent by the attending ophthalmologist on the patient, time spent on documentation, time spent on examination, and time spent talking with the patient. Metrics related to documentation efficiency, use of personalization features, use of team-based orders, and note length were also measured from the EHR efficiency portal and compared with averages for ophthalmologists nationwide using the same EHR.

Results Time spent on exclusive face-to-face communication with patients initially decreased with EHR implementation (2.9 to 2.3 minutes, p = 0.005) but returned to the paper baseline by 6 months (2.8 minutes, p = 0.99). Observed participants outperformed national averages of ophthalmologists using the same vendor system on documentation time per appointment, number of customized note templates, number of customized order lists, utilization of team-based orders, note length, and time spent after-hours on EHR use.

Conclusion Informatics-enabled QI interventions can promote patient-centeredness and face-to-face communication in high-volume outpatient ophthalmology encounters. By employing an array of interventions, time spent exclusively talking with the patient returned to levels equivalent to paper charts by 6 months after EHR implementation. This was achieved without requiring EHR redesign, use of scribes, or excessive after-hours work. Documentation efficiency can be achieved using interventions promoting personalization and team-based workflows. Given their efficacy in preserving face-to-face physician–patient interactions, these strategies may help alleviate risk of physician burnout.

Keywords

electronic health records - ophthalmology - quality improvement - informatics - communication

Protection of Human and Animal Subjects

The study adhered to the tenets of the Declaration of Helsinki and was reviewed and approved by the UCSD Institutional Review Board. Animal subjects were not included.


 

  • References

  • 1 Shanafelt TD, Hasan O, Dyrbye LN. , et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc 2015; 90 (12) 1600-1613
    CrossrefPubMedGoogle Scholar
  • 2 Jha A, Iliff A, Chaoui A. , et al. A crisis in health care: a call to action on physician burnout. AHRQ Patient Safety Network. Available at: https://psnet.ahrq.gov/resources/resource/32662/A-Crisis-in-Health-Care-A-Call-to-Action-on-Physician-Burnout . Accessed July 19, 2019
    PubMedGoogle Scholar
  • 3 Merritt Hawkins. 2018 Survey of America's physicians: practice patterns and perspectives. Available at: www.merritthawkins.com/news-and-insights/thought-leadership/survey/2018-survey-of-americas-physicians-practice-patterns-and-perspectives/ . Accessed July 19, 2019
    PubMedGoogle Scholar
  • 4 Sinsky C, Colligan L, Li L. , et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med 2016; 165 (11) 753-760
    CrossrefPubMedGoogle Scholar
  • 5 Arndt BG, Beasley JW, Watkinson MD. , et al. Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations. Ann Fam Med 2017; 15 (05) 419-426
    CrossrefPubMedGoogle Scholar
  • 6 Tai-Seale M, Olson CW, Li J. , et al. Electronic health record logs indicate that physicians split time evenly between seeing patients and desktop medicine. Health Aff (Millwood) 2017; 36 (04) 655-662
    CrossrefPubMedGoogle Scholar
  • 7 Wright AA, Katz IT. Beyond burnout - redesigning care to restore meaning and sanity for physicians. N Engl J Med 2018; 378 (04) 309-311
    CrossrefPubMedGoogle Scholar
  • 8 Collier R. Rethinking EHR interfaces to reduce click fatigue and physician burnout. CMAJ 2018; 190 (33) E994-E995
    CrossrefPubMedGoogle Scholar
  • 9 Robertson SL, Robinson MD, Reid A. Electronic health record effects on work-life balance and burnout within the I3 Population Collaborative. J Grad Med Educ 2017; 9 (04) 479-484
    CrossrefPubMedGoogle Scholar
  • 10 Medscape. Medscape National Physician Burnout & Depression Report 2018. Available at: www.medscape.com/slideshow/2018-lifestyle-burnout-depression-6009235 . Accessed February 11, 2019
    PubMedGoogle Scholar
  • 11 Mitsch C, Huber P, Kriechbaum K. , et al. eHealth 2015 special issue: impact of electronic health records on the completeness of clinical documentation generated during diabetic retinopathy consultations. Appl Clin Inform 2015; 6 (03) 478-487
    Article in Thieme ConnectPubMedGoogle Scholar
  • 12 Saleem JJ, Flanagan ME, Russ AL. , et al. You and me and the computer makes three: variations in exam room use of the electronic health record. J Am Med Inform Assoc 2014; 21 (e1): e147-e151
    CrossrefPubMedGoogle Scholar
  • 13 Frankel R, Altschuler A, George S. , et al. Effects of exam-room computing on clinician-patient communication: a longitudinal qualitative study. J Gen Intern Med 2005; 20 (08) 677-682
    CrossrefPubMedGoogle Scholar
  • 14 Rizer MK, Sieck C, Lehman JS, Hefner JL, Huerta TR, McAlearney AS. Working with an electronic medical record in ambulatory care: a study of patient perceptions of intrusiveness. Perspect Health Inf Manag 2017; 14 (Winter): 1g
    PubMedGoogle Scholar
  • 15 Ross JS. Making electronic health records work better for patient care. JAMA Intern Med 2016; 176 (04) 560-560
    PubMedGoogle Scholar
  • 16 Shachak A, Reis S. The impact of electronic medical records on patient-doctor communication during consultation: a narrative literature review. J Eval Clin Pract 2009; 15 (04) 641-649
    CrossrefPubMedGoogle Scholar
  • 17 Ehrlich JR, Michelotti M, Blachley TS. , et al. A two-year longitudinal assessment of ophthalmologists' perceptions after implementing an electronic health record system. Appl Clin Inform 2016; 7 (04) 930-945
    Article in Thieme ConnectPubMedGoogle Scholar
  • 18 Guo U, Chen L, Mehta PH. Electronic health record innovations: helping physicians - one less click at a time. Health Inf Manag 2017; 46 (03) 140-144
    PubMedGoogle Scholar
  • 19 Rizvi RF, Marquard JL, Seywerd MA. , et al. Usability evaluation of an EHR's clinical notes interface from the perspective of attending and resident physicians: an exploratory study. Stud Health Technol Inform 2017; 245: 1128-1132
    PubMedGoogle Scholar
  • 20 Zahabi M, Kaber DB, Swangnetr M. Usability and safety in electronic medical records interface design: a review of recent literature and guideline formulation. Hum Factors 2015; 57 (05) 805-834
    CrossrefPubMedGoogle Scholar
  • 21 Turchin A, Sawarkar A, Dementieva YA, Breydo E, Ramelson H. Effect of EHR user interface changes on internal prescription discrepancies. Appl Clin Inform 2014; 5 (03) 708-720
    Article in Thieme ConnectPubMedGoogle Scholar
  • 22 Bosse C, Kelly K. Improving EHR usability using LEAN methodology. Stud Health Technol Inform 2016; 225: 870
    PubMedGoogle Scholar
  • 23 Hultman G, Marquard J, Arsoniadis E. , et al. Usability testing of two ambulatory EHR navigators. Appl Clin Inform 2016; 7 (02) 502-515
    Article in Thieme ConnectPubMedGoogle Scholar
  • 24 Gidwani R, Nguyen C, Kofoed A. , et al. Impact of scribes on physician satisfaction, patient satisfaction, and charting efficiency: a randomized controlled trial. Ann Fam Med 2017; 15 (05) 427-433
    CrossrefPubMedGoogle Scholar
  • 25 Shultz CG, Holmstrom HL. The use of medical scribes in health care settings: a systematic review and future directions. J Am Board Fam Med 2015; 28 (03) 371-381
    CrossrefPubMedGoogle Scholar
  • 26 Golob Jr JF, Como JJ, Claridge JA. Trauma surgeons save lives-scribes save trauma surgeons!. Am Surg 2018; 84 (01) 144-148
    CrossrefPubMedGoogle Scholar
  • 27 Mishra P, Kiang JC, Grant RW. Association of medical scribes in primary care with physician workflow and patient experience. JAMA Intern Med 2018; 178 (11) 1467-1472
    CrossrefPubMedGoogle Scholar
  • 28 Zallman L, Finnegan K, Roll D, Todaro M, Oneiz R, Sayah A. Impact of medical scribes in primary care on productivity, face-to-face time, and patient comfort. J Am Board Fam Med 2018; 31 (04) 612-619
    CrossrefPubMedGoogle Scholar
  • 29 Cowan TL, Dunlop WA, Ben-Meir M. , et al. Emergency consultants value medical scribes and most prefer to work with them, a few would rather not: a qualitative Australian study. Emerg Med J 2018; 35 (01) 12-17
    CrossrefPubMedGoogle Scholar
  • 30 Pranaat R, Mohan V, O'Reilly M. , et al. Use of simulation based on an electronic health records environment to evaluate the structure and accuracy of notes generated by medical scribes: proof-of-concept study. JMIR Med Inform 2017; 5 (03) e30
    CrossrefPubMedGoogle Scholar
  • 31 Hribar MR, Read-Brown S, Goldstein IH. , et al. Secondary use of electronic health record data for clinical workflow analysis. J Am Med Inform Assoc 2018; 25 (01) 40-46
    CrossrefPubMedGoogle Scholar
  • 32 Baxter SL, Gali HE, Huang AE. , et al. Time requirements of paper-based clinical workflows and after-hours documentation in a multi-specialty academic ophthalmology practice. Am J Ophthalmol 2019; ;(March): S0002-9394(19)30120-5
    PubMedGoogle Scholar
  • 33 Read-Brown S, Hribar MR, Reznick LG. , et al. Time requirements for electronic health record use in an academic ophthalmology center. JAMA Ophthalmol 2017; 135 (11) 1250-1257
    CrossrefPubMedGoogle Scholar
  • 34 Chiang MF, Read-Brown S, Tu DC. , et al. Evaluation of electronic health record implementation in ophthalmology at an Academic medical center (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc 2013; 111: 70-92
    PubMedGoogle Scholar
  • 35 Pandit RR, Boland MV. The impact of an electronic health record transition on a glaucoma subspecialty practice. Ophthalmology 2013; 120 (04) 753-760
    CrossrefPubMedGoogle Scholar
  • 36 Lim MC, Boland MV, McCannel CA. , et al. Adoption of electronic health records and perceptions of financial and clinical outcomes among ophthalmologists in the United States. JAMA Ophthalmol 2018; 136 (02) 164-170
    CrossrefPubMedGoogle Scholar
  • 37 Sieja A, Markley K, Pell J. , et al. Optimization sprints: improving clinician satisfaction and teamwork by rapidly reducing electronic health record burden. Mayo Clin Proc 2019; 94 (05) 793-802
    CrossrefPubMedGoogle Scholar
  • 38 Longhurst CA, Davis T, Maneker A. , et al; Arch Collaborative. Local investment in training drives electronic health record user satisfaction. Appl Clin Inform 2019; 10 (02) 331-335
    Article in Thieme ConnectPubMedGoogle Scholar
  • 39 Stevens LA, DiAngi YT, Schremp JD. , et al. Designing an individualized EHR learning plan for providers. Appl Clin Inform 2017; 8 (03) 924-935
    Article in Thieme ConnectPubMedGoogle Scholar
  • 40 Downing NL, Bates DW, Longhurst CA. Physician burnout in the electronic health record era: are we ignoring the real cause?. Ann Intern Med 2018; 169 (01) 50-51
    CrossrefPubMedGoogle Scholar
  • 41 Baumann LA, Baker J, Elshaug AG. The impact of electronic health record systems on clinical documentation times: a systematic review. Health Policy 2018; 122 (08) 827-836
    CrossrefPubMedGoogle Scholar
  • 42 Poissant L, Pereira J, Tamblyn R, Kawasumi Y. The impact of electronic health records on time efficiency of physicians and nurses: a systematic review. J Am Med Inform Assoc 2005; 12 (05) 505-516
    CrossrefPubMedGoogle Scholar
  • 43 Institute for Healthcare Improvement. Science of improvement: establishing measures. Available at: http://www.ihi.org:80/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx . Accessed December 16, 2019
    PubMedGoogle Scholar
  • 44 Press Ganey. Patient experience - patient-centered care. Available at: https://www.pressganey.com/solutions/patient-experience . Accessed July 26, 2019
    PubMedGoogle Scholar
  • 45 R Core Team. R: a language and environment for statistical computing. 2013 . Available at: http://www.R-project.org/ . Accessed January 8, 2020
    PubMedGoogle Scholar
  • 46 KLAS. Making sense of EHR satisfaction - KLAS blog. Available at: https://klasresearch.com/resources/blogs/2018/09/12/making-sense-of-ehr-satisfaction . Accessed May 29, 2019
    PubMedGoogle Scholar