Implementing EHRs in Eyecare with a Focus on Sustainability

Electronic health record (EHR) use has increased substantially over the past few decades. In 2021, four in five office-based physicians (78%) and almost all non-federal acute care hospitals (96%) in the US had adopted a certified EHR—up from 17% and 9%, respectively, in 2008.¹

Multiple factors have spurred this growth, including increased information access and transfer, error reduction, and clinical and administrative efficiencies that lead to time savings, staff retention, and improved health outcomes.²

An additional motivator is the perceived environmental benefits of moving away from paper-based systems that generate large volumes of emissions and waste³—but the environmental impact of implementing such a change is just starting to be uncovered.

Given that the healthcare sector is a key contributor to global greenhouse gas emissions,⁴ over 90% of ophthalmologists are concerned about global warming, and more than 50% would consider moving to surgical centers with more sustainable practices.⁵

As such, can switching to EHRs aid sustainability efforts—and, if so, how should they be implemented?

3 ways EHRs can potentially increase sustainability

How are EHRs affecting eyecare practitioners’ ability to practice sustainable healthcare? Cassandra Thiel, PhD, assistant professor at the Department of Population Health and the Department of Ophthalmology at NYU Langone Health, New York, and a specialist in sustainable healthcare and green buildings, offered her insights into this question.

According to Dr. Thiel, there are three ways EHRs can aid practices’ environmental efforts:

Increasing practitioners’ ability to provide preventive and primary care to patients: Which could potentially make it easier to minimize the need for urgent or emergent care later on.
Reducing patient travel: “This is definitely harder in eyecare, where the patient still needs to be physically present for most exams,” Dr. Thiel says. “However, models show that strategic clinic placement and the use of telemedicine could still help reduce patient travel.” This assumes that patients are using powered vehicles; if they were all walking or biking, the benefits would be reduced.
Documenting resource consumption while providing care: This depends on how the EHR is used. “Not every system documents material or supply use through the EHR,” explains Dr. Thiel. “We often do this in the US for surgeries, because we then bill the patients’ insurance for every item used. If the EHR doesn’t include that function, there may be other electronic systems that can track supply ordering or use, which can help eyecare professionals determine whether that use needs to be optimized or adjusted to create more sustainable care.”

However, these environmental benefits are not guaranteed. There can be a lot of variability in how much EHRs can enhance sustainable practices—something demonstrated by Aravind Eye Care System’s transition from paper to electronic recordkeeping.

Case study: Aravind Eye Care System

In 2018, Aravind Eye Care System, a high-volume eyecare facility in southern India, replaced its paper records with an EHR system. Dr. Thiel and her team calculated and compared the environmental emissions associated with each system. They found that Aravind’s switch to EHRs greatly expanded practitioners’ ability to provide care and patients’ access to that care.³

“With the EHR, doctors across the system can access information about a patient. No one needs to be with the patient physically to see their history; they just need an internet connection,” she explains. “In the work I’ve done with Aravind Eye Care System, the EHR has allowed them to expand their primary and secondary treatment networks. They’ve built small clinics staffed by mid-level ophthalmic professionals out in the community.”

These clinics, now within walking distance for more people, allow easier access and quicker care for eye issues. If tertiary services are needed, these can be triaged locally, rather than patients having to travel long distances and wait in long lines—factors that can lead some patients to avoid or delay treatment. Additionally, with these clinics, EHR, and telehealth services, patients can obtain eyeglass prescriptions and pick out their frames in the clinic.

Electronic doesn’t necessarily equal sustainable

Despite the benefits that EHRs brought to Aravind, changing to an electronic system not only didn’t reduce environmental emissions—it actually made them worse. “I was surprised by how much worse the EHR functioned environmentally compared with the paper record-keeping system,” Dr. Thiel says.

“Aravind’s Pondicherry hospital had made a kind of artwork out of their paper storage system—in a two-story atrium at its entrance, the whole left side was a glass wall peeking into rows and rows of paper files. It was beautiful, yet easy to visualize all that paper as the trees they once were. It’s harder to visualize the environmental impact of electricity and electronics.”

However, there are two caveats to the researchers’ calculations. First, they didn’t look at changes to care pathways—the clinical network—that likely reduce greenhouse gas emissions from patients’ car travel. Additionally, they didn’t assess the impact of providing better preventive and primary care, which could reduce the need for more intensive surgeries or other costs associated with poor vision, such as accidents and injuries.

Comparing the environmental impact of paper and electronic systems

“The study couldn’t address the shift in care patterns; it’s likely the reduction in travel by patients would outweigh the emissions caused by the electronics,” explains Dr. Thiel. Even with these caveats, their results show that electronic systems require a lot of mining, which can be far more destructive than the forestry needed to produce paper.

“Forestry removes a potentially renewable resource,” explains Dr. Thiel. “Provided that we don’t harvest more trees than nature can regrow, we’ll have more trees to use. But the oil, gas, coal, and precious metals we mine from the earth to make electricity and computers—that’s not going to be restored underground within our lifetimes.

These non-renewable resources and mines also often destroy the original habitat (including trees) and, when burned to generate electricity, emit greenhouse gases that further degrade our planetary life systems. It’s less visible, but EHR systems, if not implemented with sustainability or circularity in mind, can have far worse effects on our planet than paper.”

4 ways to sustainably implement EHRs

If making the switch to EHRs doesn’t guarantee that your practice will be more sustainable, what can you do to maximize the environmental potential of these tools? Dr. Thiel offers four considerations:

1. Decarbonize your electricity sources.

This will help with the footprint of not only your EHRs, but your entire practice. If you can’t directly decarbonize, lobby those in power (such as landlords or governments) to invest in non-fossil fuel-based energy.

The Aravind study’s sensitivity analyses showed massive variation in emissions depending on how electricity was sourced and how hardware was used. This is a good thing, because it means that there are ways to make EHRs nearly equivalent to paper systems when it comes to environmental emissions.

Basically, we can use the EHR to improve care and access—and emissions associated with that—alongside reducing emissions from direct use of the EHR.

2. Think about your EHR infrastructure holistically.

Buy only what you need to provide safe care. Extend the lifetime of your machines as much as possible by ensuring regular maintenance and proper treatment. Remove policies that mandate replacing equipment at a set point; instead, consider “circular” business models with your potential vendors or suppliers.

Instead of buy and trash, find vendors who take back electronics and refurbish or recycle the equipment. Definitely consider buying refurbished equipment; often, the quality and warranties make these just like new products.

If there aren’t vendors who directly engage in circularity, look into groups who do electronics recycling (e-waste) well. Improper e-waste disposal or recycling can cause environmental and public health issues. The idea of circularity is eliminating the need for all those mines, instead keeping those resources ‘circling’ in our economy and retaining the value of our electronic equipment.”

3. Consider your data storage.

“Data storage is somewhat of a gray area with EHRs. We just don’t have a lot of information yet. Like paper records, EHR data storage requires physical space; this will continue to proliferate as we see more patients year on year,” explains Dr. Thiel.

“Your data servers may be offsite and ‘out of mind’ (unlike paper records), but if they are onsite, you should again take steps to decarbonize energy use and create circularity for the required hardware. Additionally, look into efficient ventilation and air conditioning systems for these small servers, which tend to be less efficient than large, cloud-based data storage systems.”

Although it’s too early to come to strong conclusions, these considerations may also extend to the energy use and environmental footprints of the artificial intelligence (AI) tools that are increasingly being used in eyecare.

4. Get the most out of your EHR.

This can be a little more of a challenge in eyecare, but consider how you can further leverage your EHRs to reach patients more easily—whether it’s a network of clinics that reduce travel or outreach that reminds them to take their medications.

You could start using the EHR (depending on which software you’re using) to log material consumption, unused items, or waste and use that data to start optimizing your supply use.

Rethink, reduce, reuse, recycle

Ultimately, the thought process for implementing sustainable initiatives should be: rethink, reduce, reuse, recycle. “Look at your practice in the big picture. All the stuff you’re using to provide care—energy, electricity, disposable supplies, PPE, capital equipment, reusable supplies, and more—can be optimized, reduced, decarbonized, and made more circular,” Dr. Thiel says.

Making such changes may require collaborations with groups like EyeSustain, professional societies, or local governments and non-profits, but some of it can be done in-house.

For practitioners looking for frameworks to help in this journey, alongside those provided by EyeSustain, Dr. Thiel offers:^6,7

A paper she wrote that guides through the process of making big-picture sustainable changes
Another from NYU Stern on assessing the financial implications of decarbonization (primarily focused on US health systems)

“All of it is important. There really isn’t a step too small as long as it is one of many steps.”