Feedback on “The Impact of Workflow Modifications in an Electronic Medical Record on Tertiary Service Referrals for Patients with Visual Impairment in New York City” [Letter]

Dear editor

The article “The Impact of Workflow Modifications in an Electronic Medical Record on Tertiary Service Referrals for Patients with Visual Impairment in New York City” provides valuable evidence that structured EMR enhancements namely automated referral forms, visual status patient flags, and a Best Practice Advisory (BPA) can substantially increase access to low vision rehabilitation, with referral volumes rising sharply after each intervention.¹ This reinforces broader findings that clinical decision support tools improve referral consistency and reduce missed opportunities for rehabilitation.² Despite its strengths, the study’s retrospective design limits causal inference, and referral criteria relying solely on Snellen acuity exclude key functional indicators such as contrast sensitivity or visual fields, which are known to influence rehabilitation needs.³ Moreover, barriers to scheduling are explored only for 2023 and lack qualitative data, even though older adults often face multidimensional obstacles including mobility limitations, low health literacy, and long standing adaptation to visual loss that reduce service uptake.⁴ The multi institution expansion is described narratively without comparative evaluation, limiting insights into contextual variability. To strengthen future work, the authors could incorporate mixed methods approaches to understand patient and provider perspectives, broaden BPA logic to include functional visual metrics, and adopt interoperable data exchange frameworks for integrating low vision reports directly into the EMR. These refinements would improve the explanatory depth of referral patterns and enhance equitable access to low vision services across diverse populations.