One of the most pressing contemporary challenges confronting ophthalmologists and optometrists is balancing efficiency of practice management with quality of patient care, including time spent speaking directly with patients.
At Johns Hopkins University in Baltimore, Maryland, Michael V. Boland, MD, PhD, and Ravi R. Pandit, a fourth-year MD/MPH student, have been exploring this issue as it relates to the Glaucoma Center of Excellence at Wilmer Eye Institute at Johns Hopkins.
Quality of care – from the patient’s point of view – is also examined in the documentary film Going Blind: Coming Out of the Dark about Vision Loss. Going Blind is producer/director Joe Lovett’s personal story of his ongoing struggle with glaucoma and his halting progress through the vision rehabilitation system.
The Johns Hopkins Experience
Dr. Boland and Mr. Pandit first examined this issue in Glaucoma and Electronic Health Records (EHR): A Clinic Case History in the August 2012 online edition of Review of Ophthalmology. Here’s an excerpt from their study:
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 [electronic] 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.
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.
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.
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.
… 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.
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.)
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.
Dr. Boland and Mr. Pandit also published these results in Ophthalmology, the journal of the American Academy of Ophthalmology, in a January 2013 article entitled The Impact of an Electronic Health Record Transition on a Glaucoma Subspecialty Practice.
An Additional Johns Hopkins Transition: Telemedicine
The Johns Hopkins team is now examining the potential benefits of telemedicine as an alternative glaucoma care model. In a recent interview with Ophthalmology Times, Ravi Pandit explained this new model of patient care:
Projections on ophthalmology workforce size in the future—as well as growth in patient demand for services—indicates a clear need for more efficient delivery of glaucoma care. Going on the assumption that a tele-ophthalmological approach offers a possible solution, researchers at Johns Hopkins undertook a survey to gauge patient acceptance.
Fifty-nine adult patients with glaucoma were included in the survey that was designed to capture perceptions on current care delivery and the proposed model. The results showed that 91% of the surveyed patients were satisfied with the existing frequency of their clinic visits, and that a slight majority (58%) would be in favor of the new model.
“We have the need for an alternative care model and the technology to carry out the tele-ophthalmological approach,” said Ravi Pandit, MPH, a fourth-year medical student, Dana Center for Preventive Ophthalmology Wilmer Eye Hospital, Baltimore. “However, implementation will be a challenge if we are unable to engage patient cooperation.”
“Patients who have more visits are probably the sickest and the ones who would benefit most from the alternative-care model as they would get more time with their ophthalmologist,” he said. “This information needs to be communicated to these patients.”
“Going Blind”: the Patients Speak
Since its debut in 2010, Going Blind has ignited dialogue throughout the vision loss and medical communities. The following passages are excerpted (with permission) from the hundreds of reader responses that filmmaker Joe Lovett receives after each of the now-hundreds of Going Blind screenings throughout the country:
- Another in a long string of unacceptable, frustrating interactions with an ophthalmologist has just re-confirmed the need for a real shift in the landscape of glaucoma treatment.
- My doctor is not interested in, and is not going to discuss, my glaucoma, a disease I am going to have for the rest of my life. If I can dig deep enough, I can find questions to ask and perhaps get answers to; but what about what I don’t know enough about to ask? Why is the burden on me, the patient?
- From discussions at a glaucoma support group I have become aware that few glaucoma patients have ever been shown their own visual fields, let alone received a serious explanation of the practical consequences.
- I have no doubt that both the doctors I have seen are technically top-notch and that they have done all the tests, imaging, and diagnostics necessary to manage my disease as best they can. Neither, however, has made me a part of the process of dealing with this disease.
- I know that the “system” often forces doctors to spend less than optimum time with each patient. A prestigious [eye care practice] could have resources available for the patient to learn more – a website, literature, support/education groups.
Readers: Do you have an opinion about a model of care that works for you? How can we best combine the imperatives of practice efficiency and doctor/patient communication? Your comments on this issue are always welcome.