Mansi Parikh

Optical coherence tomography angiography of optic disc perfusion in glaucoma.

PURPOSE To compare optic disc perfusion between normal subjects and subjects with glaucoma using optical coherence tomography (OCT) angiography and to detect optic disc perfusion changes in glaucoma. DESIGN Observational, cross-sectional study. PARTICIPANTS Twenty-four normal subjects and 11 patients with glaucoma were included. METHODS One eye of each subject was scanned by a high-speed 1050-nm-wavelength swept-source OCT instrument. The split-spectrum amplitude-decorrelation angiography (SSADA) algorithm was used to compute 3-dimensional optic disc angiography. A disc flow index was computed from 4 registered scans. Confocal scanning laser ophthalmoscopy (cSLO) was used to measure disc rim area, and stereo photography was used to evaluate cup/disc (C/D) ratios. Wide-field OCT scans over the discs were used to measure retinal nerve fiber layer (NFL) thickness. MAIN OUTCOME MEASURES Variability was assessed by coefficient of variation (CV). Diagnostic accuracy was assessed by sensitivity and specificity. Comparisons between glaucoma and normal groups were analyzed by Wilcoxon rank-sum test. Correlations among disc flow index, structural assessments, and visual field (VF) parameters were assessed by linear regression. RESULTS In normal discs, a dense microvascular network was visible on OCT angiography. This network was visibly attenuated in subjects with glaucoma. The intra-visit repeatability, inter-visit reproducibility, and normal population variability of the optic disc flow index were 1.2%, 4.2%, and 5.0% CV, respectively. The disc flow index was reduced by 25% in the glaucoma group (P = 0.003). Sensitivity and specificity were both 100% using an optimized cutoff. The flow index was highly correlated with VF pattern standard deviation (R(2) = 0.752, P = 0.001). These correlations were significant even after accounting for age, C/D area ratio, NFL, and rim area. CONCLUSIONS Optical coherence tomography angiography, generated by the new SSADA, repeatably measures optic disc perfusion and may be useful in the evaluation of glaucoma and glaucoma progression.

Secondary use of electronic health record data for clinical workflow analysis

Objective Outpatient clinics lack guidance for tackling modern efficiency and productivity demands. Workflow studies require large amounts of timing data that are prohibitively expensive to collect through observation or tracking devices. Electronic health records (EHRs) contain a vast amount of timing data - timestamps collected during regular use - that can be mapped to workflow steps. This study validates using EHR timestamp data to predict outpatient ophthalmology clinic workflow timings at Oregon Health and Science University and demonstrates their usefulness in 3 different studies. Materials and Methods Four outpatient ophthalmology clinics were observed to determine their workflows and to time each workflow step. EHR timestamps were mapped to the workflow steps and validated against the observed timings. Results The EHR timestamp analysis produced times that were within 3 min of the observed times for >80% of the appointments. EHR use patterns affected the accuracy of using EHR timestamps to predict workflow times. Discussion EHR timestamps provided a reasonable approximation of workflow and can be used for workflow studies. They can be used to create simulation models, analyze EHR use, and quantify the impact of trainees on workflow. Conclusion The secondary use of EHR timestamp data is a valuable resource for clinical workflow studies. Sample timestamp data files and algorithms for processing them are provided and can be used as a template for more studies in other clinical specialties and settings.

Time requirements for electronic health record use in an academic ophthalmology center

Importance Electronic health record (EHR) systems have transformed the practice of medicine. However, physicians have raised concerns that EHR time requirements have negatively affected their productivity. Meanwhile, evolving approaches toward physician reimbursement will require additional documentation to measure quality and cost of care. To date, little quantitative analysis has rigorously studied these topics. Objective To examine ophthalmologist time requirements for EHR use. Design, Setting, and Participants A single-center cohort study was conducted between September 1, 2013, and December 31, 2016, among 27 stable departmental ophthalmologists (defined as attending ophthalmologists who worked at the study institution for ≥6 months before and after the study period). Ophthalmologists who did not have a standard clinical practice or who did not use the EHR were excluded. Exposures Time stamps from the medical record and EHR audit log were analyzed to measure the length of time required by ophthalmologists for EHR use. Ophthalmologists underwent manual time-motion observation to measure the length of time spent directly with patients on the following 3 activities: EHR use, conversation, and examination. Main Outcomes and Measures The study outcomes were time spent by ophthalmologists directly with patients on EHR use, conversation, and examination as well as total time required by ophthalmologists for EHR use. Results Among the 27 ophthalmologists in this study (10 women and 17 men; mean [SD] age, 47.3 [10.7] years [median, 44; range, 34-73 years]) the mean (SD) total ophthalmologist examination time was 11.2 (6.3) minutes per patient, of which 3.0 (1.8) minutes (27% of the examination time) were spent on EHR use, 4.7 (4.2) minutes (42%) on conversation, and 3.5 (2.3) minutes (31%) on examination. Mean (SD) total ophthalmologist time spent using the EHR was 10.8 (5.0) minutes per encounter (range, 5.8-28.6 minutes). The typical ophthalmologist spent 3.7 hours using the EHR for a full day of clinic: 2.1 hours during examinations and 1.6 hours outside the clinic session. Linear mixed effects models showed a positive association between EHR use and billing level and a negative association between EHR use per encounter and clinic volume. Each additional encounter per clinic was associated with a decrease of 1.7 minutes (95% CI, -4.3 to 1.0) of EHR use time per encounter for ophthalmologists with high mean billing levels (adjusted R2 = 0.42; P = .01). Conclusions and Relevance Ophthalmologists have limited time with patients during office visits, and EHR use requires a substantial portion of that time. There is variability in EHR use patterns among ophthalmologists.

Treatment of Epithelial Downgrowth Masquerading as Unilateral Hypopyon Uveitis in a HLA-B27+ Individual.

ABSTRACT We report a case of an elderly woman with congenital rubella who presented with epithelial downgrowth (EDG) masquerading as hypopyon uveitis. We highlight the importance of endoscopy to completely identify all ingrowing epithelium with combined use of 5-fluorouracil to completely eradicate invading tissue.