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

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.

Fig. 1

Distributions of timing outcomes for outpatient ophthalmology encounters 2 to 3 weeks before electronic health record (EHR) implementation (“preimplementation,” n  = 227), 5 to 6 weeks after EHR implementation (“early postimplementation,” n  = 170), and 6 months after EHR implementation (“6 months postimplementation,” n  = 251). Probability densities of the data are depicted with overlying boxplots delineated by medians and interquartile ranges for total time per patient ( A ), documentation time per patient ( B ), examination time per patient ( C ), and talking time per patient ( D ).

Fig. 2

Mean proportion of time spent by ophthalmologists on various clinical activities during outpatient encounters on paper charts (“preimplementation,” n  = 227), 5 to 6 weeks after electronic health record (EHR) implementation (“early postimplementation,” n  = 170), and 6 months after EHR implementation (“6 months postimplementation,” n  = 251). The proportion of the encounter devoted to documenting initially increased in the early postimplementation period and subsequently decreased by 6 months after EHR implementation. In contrast, the proportion of the encounter devoted to exclusively talking with the patient initially decreased after EHR implementation but increased by 6 months of EHR use. The proportion of time spent on examining patients and other activities (which included activities such as performing procedures or teaching residents and fellows) remained approximately the same regardless of clinical documentation method.

Fig. 3

Patient satisfaction scores for ophthalmologists before and after electronic health record implementation in September 2018. Values are presented relative to the baseline patient satisfaction value while documenting on paper charts.