Like most ophthalmologists, those who treat glaucoma are concerned about how switching to electronic health records will affect their practices. Will it compromise their ability to see the same number of patients they’re seeing now? Will the expense and effort of making the transition pay off by providing significant benefits? Will the patient-doctor relationship suffer?

Our Wilmer Eye Institute glaucoma clinic was the first in our department to transition from a home-grown, mixed computer and paper system to an all-digital system. Because we were concerned about the impact of making the switch, we decided to conduct a study during the transition to see what actually occurred. By measuring specific factors such as time spent on different tasks and patient reactions, we felt we could shed some light on the concerns that ophthalmologists have and provide some insights into what strategies help to make the transition go more smoothly.

Conducting the Study

For our study, we observed the glaucoma clinic at three discrete times. First, we measured the factors we were interested in at baseline—right before we switched to the new system. Once the switch occurred, we allowed two weeks for the clinic to acclimate to the new system and then measured the same factors again. That allowed us to get a sense of what happened in the short term. Finally, about six months after the transition, we repeated the observations.

At each time point we collected three types of data. First, we measured the timing of different activities during the physician-patient interaction. How long did the physician spend talking to the patient? Examining the patient? Looking at the computer? Looking at paper charts? (Both the physician and patient were masked as to what we were measuring.)

Second, we monitored patient movement through the clinic. We recorded patients’ check-in times, when they were called for testing, when they left testing, when they saw the physician and when they left the exam room. 

Finally, after the exam, we asked patients to complete a 12-question survey about how they felt the visit had gone. How efficient did the clinic seem? How was the quality of care? 

What the Data Showed

Overall, the results were positive—although there were a few surprises. One unexpected finding was that, on average, there was an increase in time dedicated to talking to and examining the patient. That was not what we had expected.

We’re still analyzing the timing data, but anecdotally, our observations indicate that the extra time came from a change in the way physicians documented the exams. Before the switch to EHR, doctors would see their patients without doing all of the necessary documentation during the visit; some was done after the patient left. But after the switch to EHR, most of the documentation happened during the exam. As a result, as soon as one patient left, another patient was called in. So the extra time being spent on the exams was subtracted from the time between patients. 

To confirm this hypothesis, we calculated the yearly census for the clinic. We found no significant change in patient numbers between the year prior to implementation and the year after. So, the increase in time spent doing the exam didn’t result in seeing fewer patients.

We also noted that our physicians were now spending more time talking to their patients during the exam. The most likely explanation appears to be the nature of today’s EHR systems. In the past, a computerized documentation system was pretty much a blank document into which you typed your findings. The only questions you asked during the exam were those that occurred to you at the time. In contrast, the new systems have checklists and drop-down boxes—mandatory fields that prompt increased disclosure, because there are questions on those forms that many of us might not have asked. In effect, the system is acting as a fail-safe. This may explain the increased time spent talking to the patient.

Although ophthalmologists agree that no current EHR system is perfect, an intelligently designed and customized system can prompt the doctor to ask key questions that might be overlooked, provide a quick overview of a patient’s history, show data in graphic form, minimize repetitive data entry and prevent data from being lost.

Is this a good thing? That depends on how relevant the questions are. (In general, we noted that when the physician felt that questions were clinically relevant they looked up and engaged the patient in conversation; if a question was considered not clinically relevant, most never looked away from the computer.) That’s why the design of the EHR system you choose is so important, and why having a system customized for ophthalmology is so valuable. You want to elicit a lot of information, but you want to be sure that the information is clinically useful.

How did patients feel about the shift to EHR? The patient survey data indicated that very little changed after implementation; patients seemed very neutral about what was going on. The only thing that changed was that patients were more likely to say that the computer interfered with their ability to talk to the physician. We expected that, because the more objective data showed that physicians were spending more time just looking at the computer or multitasking (i.e., looking at the computer while talking to the patient). But the surveys didn’t reveal any change in patient perception of quality of care, relationship to the physician or clinic efficiency.

One related thing that we noted—not a statistically significant change—was that our physicians were more likely to mention to the patient that the clinic was switching to a new system. Some even apologized for any inconvenience the switch might be causing. Which raises the question: If the doctors hadn’t called attention to the change, would the patients have noticed anything at all? There’s no way to be sure, but it’s an interesting question.

The last thing we found was that the changes that did occur—i.e., increased time with the physician talking to or examining the patient and increased time on computer-related tasks and multitasking—happened within the first two weeks and then stabilized. Many people expected changes to occur slowly over a long period of time, but at six months our data was very similar to what we found at two weeks. There was a slight downward trend (not statistically significant) in the amount of time physicians spent on the computer between two weeks and six months. That makes sense, because the doctors undoubtedly became more familiar with the system over time. But the significant changes happened at the outset.

The relative lack of change after the first two weeks is probably a good thing; it implies that if you make the switch to EHR you can evaluate how well it’s working out fairly quickly. (Furthermore, doing such an evaluation isn’t expensive; doing our study cost the clinic less than $50, plus the time required to write some simple software.)

As a side note, we did ask the physicians what they thought about the change, even though this question wasn’t part of the official study. Their sentiments pretty much reflected what you hear at conferences: EHR has a lot of potential, but there’s a long way to go. The challenge seems to be finding a balance between utility and not overburdening the physician with checklists and other mandatory documentation. Nevertheless, we noted that no one seems interested in returning to the old system.

What We’ve Learned

A typical examination lane illustrates the challenges of interacting with both the computer and patient simultaneously.
Based on our observations, here are a few bits of advice for those preparing to make the switch to EHR:

• Don’t expect a disaster. At least in our clinic, we didn’t find the switch to EHR to be particularly dramatic or catastrophic. The clinic flow didn’t really change; the proportion of time patients spent in one station of the clinic vs. another didn’t really change. The changes that did occur were subtle, and related to what happened during the time the patient spent with the physician. Many of them could be considered beneficial, including increased clinical exam time—the time dedicated to examining and talking to the patient with eye contact.

• Expect the major changes to be accomplished fairly quickly. Among other things, that means that if something isn’t working well for you, you won’t have to sit with it for six months before doing something about it. You’ll be able to make adjustments and modifications pretty quickly.

• Provide training and encourage individual experimentation. The physicians who took a few moments of their downtime to investigate the system and familiarize themselves with it before implementation did better after the switch. They experienced fewer problems and issues during patient exams. As with any EHR implementation, some investment in training on the part of the practice is very important, whether it’s formal training or just something the physician does on his own. 

Along these same lines, it’s worth remembering that different people have different comfort levels when it comes to working with computers. The doctors who familiarized themselves with the system ahead of time were undoubtedly those who felt comfortable with computers. So it may be valuable to determine which physicians in your group are less comfortable with computers and perhaps provide them with some more rudimentary training covering basic issues like keyboard shortcuts, the best ways to copy and paste, and when to single-click vs. when to double-click.

• Be sure to get help with data entry. The first three to six months were a little bit painful as we adapted to the new system, and a lot of that had to do with some patient data not being in the system. Staring at mostly blank screens when you’re with a patient you’ve been seeing for years is a little bit frustrating. Fortunately, the screens weren’t completely blank, because we spent money to get some of our prior data loaded into the system for us. And, the painful period tapered off pretty quickly as patients started coming back. Within six months, almost every patient has been in the clinic at least once, so the data got filled in. Nevertheless, the message was clear: If you make the switch to EHR without having any existing data loaded ahead of time, your productivity will take a much bigger hit.

• Don’t worry too much about patient reaction. As our survey found, patients scarcely noted the change—even with many physicians pointing it out to them.

• Don’t assume younger doctors will pick it up faster. We expected our younger, newer doctors to have an easier time with EHR, simply because they grew up using computers. But when we deployed the system in our resident clinic it wasn’t nearly as successful as we expected. The reason seems to be that the kind of computer skills you need to be effective at using EHR are not necessarily the same skills honed by using Facebook and Gmail and operating your smartphone. Certainly many of the skills you need to use EHR are not intuitive, any more than performing cataract surgery is intuitive. So although it seemed like an obvious assumption that our younger doctors would do better, it turned out not to be true.

• Don’t wait for an “ophthalmology-perfect” EHR system. So far, no system is perfect. However, there’s no point in waiting for perfection; that may never happen. The system we deployed was probably a worst-case scenario; it had no ophthalmology content built into it at all. We customized it from scratch, yet we were still able to maintain productivity. And the systems available now are far better.

Regarding the kind of EHR features that help ophthalmologists to do their jobs, the American Academy of Ophthalmology has released an official statement on the special requirements for electronic health records in ophthalmology, partly to help doctors choosing an EHR system and partly to inform the industry about our needs. Many vendors are now aiming to provide those kinds of features in their systems. Information on this was presented at last year’s annual meeting of the academy, and it’s available online for those just beginning their search for an EHR system. (Go to and search for EHR Central.) You’ll find a guide to implementing EHR, information about proposals, technical details and a list of features that are especially useful for ophthalmologists.

Unanswered Questions

Although our study provided some interesting data, there are other issues surrounding the switch to EHR that deserve further study. For example, it would be valuable to compare the quality of documentation before and after EHR. Certainly the current systems prompt us to gather more information; but it’s also very easy to copy things forward and possibly perpetuate errors. Also, it would also be useful to see if there are changes to efficiency over a longer time period.

As our survey found, patients scarcely noted the change. 
Perhaps most important, it would be worthwhile to determine how the use of EHR affects the quality of patient care we provide. Research has shown that in many respects our testing of glaucoma patients may be inadequate. We’re not doing enough visual field testing, and we’re not documenting gonioscopy on everybody. 

It would be interesting to see, for example, how we’re doing with EHR relative to the AAO Preferred Practice Patterns for management of glaucoma, compared to what we were doing before. Our EHR patient screen has a little box labeled “gonioscopy,” so if you forget to think of it, it reminds you. And the summary screen shows the results of the previous gonioscopy; if that’s blank you know there’s a problem. These kinds of things could affect our patient care for the better, but someone will need to check insurance claims data to find out whether that’s actually the case.

Outlook: Promising

At this point, we’re well into using the new system and we’re starting to appreciate its advantages. We’re able to reuse relevant information that’s already been entered, so we don’t have to redo things multiple times. And, we’re not losing data over time. (In the past, if a technician forgot to include somebody’s past medical problem or surgical history on a piece of paper, it sort of disappeared.) 

Overall, we think we now have a much more complete record for each patient. Thanks to a clinical summary page, we can now review all of the patient’s problems, medications, eye pressures over time, vision over time, the last exam findings for gonioscopy or corneal thickness, and other data relevant to glaucoma at a glance. 

Of course, as already noted, there’s plenty of room for improvement. But it’s clear that some of the shortcomings of current EHR systems will disappear as time passes. For example, we’re still using desktop computers, and with that equipment, no matter how hard you try, at some point your back will be toward the patient. But it’s easy to imagine using handheld devices for the same purpose in the near future, simulating paper and clipboard. That should make it possible to maintain the benefits of computer documentation, and still retain that old-school, facing-the-patient, clipboard-in-your-lap kind of environment. Meanwhile, the issue of insufficient ophthalmology-specific content will improve slowly but surely.

Overall, our experience making the transition was good. Any change of this magnitude is bound to be a little scary, but it appears that with a little forethought, a glaucoma practice should be able to weather the storm unscathed.  REVIEW

Dr. Boland is assistant professor of ophthalmology and director of information technology at the Wilmer Eye Institute in Baltimore. Mr. Pandit is a fourth-year MD/MPH student at Johns Hopkins University.