The Impact of Workflow Modifications in an Electronic Medical Record on Tertiary Service Referrals for Patients with Visual Impairment in New York City.

Purpose: Low vision services are beneficial for many patients with visual impairment. To facilitate referrals from Montefiore Medical Center in the Bronx to specialists at Lighthouse Guild (LHG), a New York City-based non-profit offering low vision services, an integrated referral system and best practice advisory (BPA), a pop-up tool used to guide clinicians toward recommended actions based on patient data, were implemented within the electronic medical record (EMR; Epic Systems). This was later expanded to nearby medical centers. The primary objectives of this retrospective study are to describe these EMR modifications and analyze how they impacted referrals to LHG low vision services. The secondary objective is to understand barriers to evaluation through an analysis of scheduling rates on an index year (2023). Patients and Methods: We analyzed referrals to LHG from Montefiore's Department of Ophthalmology along with other local institutions between 2015 (baseline year) to 2023. Patient demographic data were extracted from Montefiore Epic. Referral volumes were obtained from LHG and trended over time to determine the impact of sequential workflow modifications and regional expansions. Descriptive statistics and a chi-square analysis were performed to compare patients successfully scheduled for LHG services in 2023 with those who were referred but not scheduled. Results: Referrals to LHG increased by 220% from 2016-2017 (N=45 to 144). A flag indicating a patient's visual status resulted in a 65% year-to-year increase in 2019 (N=207 to 341). The BPA and expansion to nearby institutions increased total referrals by 90% (N=573 to 1,090). Older individuals referred to LHG were less likely to schedule appointments than younger individuals (67 vs 60 years old) (p=0.0090). Conclusion: An EMR-based system designed to alert clinicians of visual deficits and enable real-time referrals dramatically improved access to low vision services. Further integration of services and coordination of care should focus on vulnerable patients such as the elderly.