In February, JAMA Ophthalmology published a survey authored by Michele Lim, MD, UC Davis Health, regarding doctor perceptions of elec­tronic health records systems.  

In the population-based, cross-sectional study,1 researchers looked at a random sample of ophthalmologists from the American Academy of Ophthalmology’s active membership database. They found that the adoption rate of EHRs among the 348 responding ophthalmologists was 72.1 percent. The study determined, however, that despite the EHR adoption rate doubling since a previous survey in 2011, ophthalmologists report that net revenues and productivity declined and that practice costs rose with EHR use.

When asked about these surprising results, Dr. Lim says, “It’s interesting because metrics like the number of patients seen and revenues did not actually seem to change much after implementing EHRs. I think the most surprising thing is [finding out] that both of those changed for the negative. I would expect that to be a little more mixed.

“It’s pretty easy to imagine the rising costs that these EHR systems bring,” Dr. Lim continues. “You have to pay for expensive hardware equipment that you previously haven’t had to. Paper charts are a lot cheaper. Even though you can downsize people in terms of having to curate paper charts, you have to upsize positions where people monitor these systems, and that obviously takes a lot more skill. You’re hiring higher-skilled people who are going to cost more. Every practice using a cloud-based solution needs a network specialist to help them deal with all the intricacies of that, so the rising costs aren’t much of a surprise. It’s just something you have to keep in mind when implementing these systems.”

In terms of suggestions or solutions to help ophthalmologists better use these systems, Dr. Lim offers some advice. “I’m hoping that we, the Academy and other ophthalmologist groups, use this paper as a point at which we can begin to have a conversation, and to realize that there’s a growing sentiment among ophthalmologists that EHRs are not efficient because they may not be necessarily following what physicians would do naturally in their practices,” she says. “Some things need to be more intuitive. For example, why is it so hard to write a letter to a referring doctor? It definitely takes a lot of stakeholders to engage in trying to build a better system, however, so we hope that this paper starts that process.

“Some of that is on us as doctors, but there is definitely room for improvement with some of these systems,” Dr. Lim adds. “Programs like meaningful use (the federal incentive) seem to be detrimental in a lot of ways. On the one hand, it was great because there was a clear explosion of EHR use after those incentives and penalties came out. However, I think that when that happened, EHR vendors paid too much attention to system design to just satisfy the meaningful-use reporting and turned their attention away from the workflow-efficiency aspect of these systems. It’s as if we’ve been focusing on the wrong thing. So there’s room for improvement, ideally with feedback from the doctors that are using these systems.”

A representative from a company that engineers these EHR systems—who chose to remain anonymous—weighed in on the results of the study. “It is surprising to see,” he says. “Obviously when you design and sell these programs, you expect them to succeed, so you hate to see something like that. But at the same time, we have standards and incentives that we have to meet with these programs. It’s just difficult to nail down what’s working and what isn’t when we don’t tangibly see how it affects or betters a practice. But this study is starting to reveal those effects, so there will certainly be interesting discussions going forward as to how we can modify and optimize our programs. Hopefully we will be working closely with physicians to see how to best optimize the programs for their practices.”

Another representative, also anonymous, from a competing company shared his thoughts about the study, saying, “Honestly, we’re not seeing a lot of complaints with our system. There are definitely things we can tweak, but we try to consistently update our EHR. I think a lot of these surprising results fall to the doctors who are using the systems. Maybe they’re just not using the systems efficiently, or don’t have a staff that understands or takes advantage of the systems. We have absolutely seen it work in practices. There’s a learning curve, but there’s not much we can do about that on our end.”

1. 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;136:2:164-170.

ReVision Shuts Down

In late January, ReVision Optics, maker of the Raindrop corneal inlay for the treatment of presbyopia, closed its doors. The Raindrop was only the second such inlay approved in the United States, and the shuttering leaves the AcuFocus Kamra inlay as the only approved corneal device available for this indication in the U.S.

Patients or physicians who visited the ReVision homepage the day of the closure were met with this message from the company: “ReVision Optics, the maker of the Raindrop Near Vision Inlay, made great strides to build a market for the surgical correction of presbyopia, but respectful of our best efforts, it is with regret that we have to close our doors. The Raindrop Inlay will not be sold to ophthalmic practices or distributors as of Tuesday, January 30, 2018. As a result, the Raindrop Rebate will not be honored past this date. To address any questions you may have in the near-term, we have established a Hotline Number, 1-866-934-6592, which will be staffed through April 30, 2018 ...”

John Hovanesian, MD, a Raindrop user who also participated in the inlay’s FDA trial, says his experience was positive, but that the inlay may have faced an uphill battle from the start. “The decision by ReVision Optics’ board to close their operation is an unfortunate side effect of too-slow market adoption of a new technology,” he says. “From my perspective as a user of their products, an investigator in two of their trials and a close advisor to the company, I have always been impressed with their management, their research and development group, and their commercial operations. The technology itself was a good performer—good enough that I implanted two inlays in close, personal friends, both of whom were quite happy. Personally, I believe the slow adoption of the Raindrop inlay was attributable to the ‘competition’ of LASIK and premium IOLs’ great results. While neither procedure is ideally suited to the emmetropic presbyope who was a candidate for Raindrop, both have received wide public acceptance and adoption by surgeons. In addition, achieving a quiet eye with the Raindrop inlay required more follow-up and diligence after surgery than other refractive procedures.

“AcuFocus has an aperture IOL in the pipeline that, if approved, may pave the way for broader acceptance of small-aperture inlays,” he continues.  “That may be our best hope of having broad market acceptance of inlay procedures.”  REVIEW