Creating an Evidence Base for Vision Rehabilitation

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Project Details -
Completed

The project, "Creating an Evidence Base for Vision Rehabilitation," involved the implementation of the newly developed Electronic Vision Rehabilitation Record (EVRR). The lead agency on this project, Lighthouse International, built this software and the model upon which it is based. The project involved the installation and implementation of EVRR at Lighthouse International, The Iris Network in Maine, and the Central Association for the Blind and Visually Impaired (CABVI) in Utica, New York. The project also involved the installation of EVRR modules at three offices of the New York State Commission for the Blind and Visually Handicapped (CBVH) and three ophthalmologists' private offices or primary eye-care services within hospitals. The implementation of EVRR and its tools assured that patients receive consistent, high-quality, standardized care thereby delaying the functional decline that has been associated with increased utilization of health services. Over a relatively short period of time, the system created a large outcome-measures database by which to evaluate the effectiveness of current best practice and help refine practice as the evidence indicates.

Cynthia Stuen, PhD
When it comes to providing rehabilitation care for the visually impaired, data describing quality or outcomes of treatment are few and far between. But a unique computerized record system developed and implemented by New York-based Lighthouse International with funding from the Agency for Healthcare Research and Quality (AHRQ) aims to change that.

The Electronic Vision Rehabilitation Record (EVRR®)** is the first Web-enabled electronic record system that is focused on best practices of care for people who are visually impaired. Eventually, EVRR® will register patient data and track functional outcomes, allowing providers to demonstrate the impact of their services to funders and payers -- and advance the standard of care. Under the AHRQ grant, EVRR® is being implemented by Lighthouse in the New York City area; the Central Association for the Blind and Visually Handicapped in Utica, NY; and The Iris Network in Portland, ME. In addition, EVRR® is licensed by the Canadian National Institute for the Blind for use throughout Canada.

"The field of vision rehabilitation has never had very good data on our intervention outcomes or results across providers geographically," says Cynthia Stuen, PhD, senior vice president of policy and professional affairs at Lighthouse International and principal investigator for the AHRQ project. "Say you've lost your vision and you need an orientation mobility specialist to teach you how to get from your home in Brooklyn to your job in Manhattan. How many sessions do you need to learn how to be a competent traveler? Our field has no clue -- partly because we've never had a national database of evidence-based practice outcomes." EVRR® may one day serve as that database, which may be international as well, with CNIB participating.

Ruth Mlotek, director of rehabilitation services for The Iris Network, notes that the services provided to the blind and visually impaired are unique. "No other field teaches people to read Braille or use the white cane. No other field teaches people how to navigate the world around them the way that we do." Occupational training is also highly specialized.

EVRR® is designed to address these and other issues.

Lighthouse International is a nonprofit organization that provides vision rehabilitation services, education, and research. During the late 1990s, Lighthouse researchers and practitioners became concerned about the lack of reliable data documenting the value of vision rehabilitation services and began to look into electronic health record (EHR) systems. However, they quickly found that none of the EHRs on the market were made for people with visual impairment. "We have visually impaired people on our staff, and nothing off the shelf was accessible to them," Dr. Stuen says.

The first EHR system that Lighthouse implemented was a client/server application that was both cumbersome and time-consuming for practitioners to deploy, use, and maintain. Ultimately, Lighthouse scrapped that system in favor of a browser-based system custom-designed for vision rehabilitation. "We did it in-house, using open source technology to keep costs low, allow rapid development, and minimize deployment and maintenance issues," says Tom Nolan, chief information officer at Lighthouse. System designers sought input from the clinical providers who had used the old system to come up with a more streamlined, accessible, and adaptable functionality.

"When we designed EVRR®, we made it really simple and involved the providers so that they became owners," says Verena Cimarolli, Ph.D., director of evaluation at Lighthouse and co-principal investigator for the AHRQ project.

A step-by-step rollout, focusing first on patient registration and then assessment, was key to a successful implementation. Several of The Iris Network's senior staff members have also served as beta testers for EVRR®. "We adopted slowly," says David Searle, director of information technology at Iris. "We wanted to make sure it worked at a certain level before we made it available for anyone else."

The next step is to use EVRR® to generate outcomes and benchmarking reports. Lighthouse says it's just beginning to get the data it needs to produce those types of reports for providers.

"I think that's going to be the best way to motivate people to use the system," says Dr. Stuen. "If they don't see data that's going to help them improve their work, they won't have any incentive to use the system and provide feedback for change."

**EVRR ® is a registered trademark of Lighthouse International