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Original Investigation | Clinical Sciences

Impact of an Electronic Health Record Operating Room Management System in Ophthalmology on Documentation Time, Surgical Volume, and Staffing

David S. Sanders, BS1; Sarah Read-Brown, BA1; Daniel C. Tu, MD1,2; William E. Lambert, PhD3; Dongseok Choi, PhD3; Bella M. Almario, RN, MPH1; Thomas R. Yackel, MD, MPH, MS4; Anna S. Brown, RN1; Michael F. Chiang, MD1,4
[+] Author Affiliations
1Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland
2Operative Care Division, Ophthalmology, Portland VA Medical Center, Portland, Oregon
3Department of Public Health and Preventive Medicine, Oregon Health & Science University, Portland
4Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
JAMA Ophthalmol. 2014;132(5):586-592. doi:10.1001/jamaophthalmol.2013.8196.
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Importance  Although electronic health record (EHR) systems have potential benefits, such as improved safety and quality of care, most ophthalmology practices in the United States have not adopted these systems. Concerns persist regarding potential negative impacts on clinical workflow. In particular, the impact of EHR operating room (OR) management systems on clinical efficiency in the ophthalmic surgery setting is unknown.

Objective  To determine the impact of an EHR OR management system on intraoperative nursing documentation time, surgical volume, and staffing requirements.

Design, Setting, and Participants  For documentation time and circulating nurses per procedure, a prospective cohort design was used between January 10, 2012, and January 10, 2013. For surgical volume and overall staffing requirements, a case series design was used between January 29, 2011, and January 28, 2013. This study involved ophthalmic OR nurses (n = 13) and surgeons (n = 25) at an academic medical center.

Exposures  Electronic health record OR management system implementation.

Main Outcomes and Measures  (1) Documentation time (percentage of operating time documenting [POTD], absolute documentation time in minutes), (2) surgical volume (procedures/time), and (3) staffing requirements (full-time equivalents, circulating nurses/procedure). Outcomes were measured during a baseline period when paper documentation was used and during the early (first 3 months) and late (4-12 months) periods after EHR implementation.

Results  There was a worsening in total POTD in the early EHR period (83%) vs paper baseline (41%) (P < .001). This improved to baseline levels by the late EHR period (46%, P = .28), although POTD in the cataract group remained worse than at baseline (64%, P < .001). There was a worsening in absolute mean documentation time in the early EHR period (16.7 minutes) vs paper baseline (7.5 minutes) (P < .001). This improved in the late EHR period (9.2 minutes) but remained worse than in the paper baseline (P < .001). While cataract procedures required more circulating nurses in the early EHR (mean, 1.9 nurses/procedure) and late EHR (mean, 1.5 nurses/procedure) periods than in the paper baseline (mean, 1.0 nurses/procedure) (P < .001), overall staffing requirements and surgical volume were not significantly different between the periods.

Conclusions and Relevance  Electronic health record OR management system implementation was associated with worsening of intraoperative nursing documentation time especially in shorter procedures. However, it is possible to implement an EHR OR management system without serious negative impacts on surgical volume and staffing requirements.

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Surgical Volume and Staffing Requirements in Ophthalmic Operating Rooms During Electronic Health Record (EHR) Implementation

Monthly totals for volume (number of procedures) and full-time equivalents were collected the year before and the year after implementation. Differences between periods were not found to be statistically significant.

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No change in volume
Posted on May 27, 2014
subrata goswami
Conflict of Interest: None Declared
A timely article with real data. Although the initial worsening in POTD during the early phase of EHR implementation can be explained by learning curve and customization for the the local environment, it would be interesting to see what fraction can be attributable to each. Also, is it interesting to note that the authors did not see any change in volume. Given that EHR appears to have additional benefits such as relatively more uniform documentation, more legible documentation, instant access to historical record, ...
Author Response
Posted on June 5, 2014
Michael Chiang
Oregon Health and Science University
Conflict of Interest: None Declared

We appreciate the comments and agree with those interesting points. In response:

  • With regard to the initial worsening in POTD: our suspicion is that what you mentioned is exactly what happened (i.e. combination of learning curve and customization). In speaking informally with our nursing staff, this is exactly their feeling as well. Of course, our study was not designed to make that distinction or to determine which fraction was attributable to each.
  • With regard to surgical volume: after a short initial implementation period, scheduling of cases returned to the baseline methods. It will be interesting to follow whether there are any trends over time.
  • With regard to why POTD for cataract remained higher: our feeling is that there are several explanations. More data elements were documented in EHR than using paper methods, the EHR data entry widgets were not always felt to be efficient, and local customization of the system is continuing to improve over time.
Case time is worse
Posted on June 10, 2014
Steven Archer
University of Michigan
Conflict of Interest: None Declared
The reason that POTD came back to baseline in the Late EHR phase is not because documentation time improved to baseline—it actually remained 23% longer. Rather, POTD came back to baseline because case time—calculated as absolute documentation time divided by POTD—increased for every procedure type except Cataract (for which long-term staffing was increased). So, longer documentation time is not a problem because we make up for it with longer case times?! The conclusion that \"it is possible to implement an EHR OR management system without serious negative impact\" is a curious lowering of the bar. If I had just spent half a billion dollars on a system, I would want to know how much it will help me, not just that it won't hurt me too badly.
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