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The Impact of Workflow Modifications in an Electronic Medical Record on Tertiary Service Referrals for Patients with Visual Impairment in New York City [Response to Letter]
Authors Allen OS 
, Fields LS, Sweeney MJ , Als SL, Seiple WH , Shrivastava A
Received 24 November 2025
Accepted for publication 16 December 2025
Published 25 December 2025 Volume 2025:19 Pages 4897—4898
Olivia S Allen,1 Lindsey S Fields,1 Maura J Sweeney,2 Shontel L Als,3 William H Seiple,2,4 Anurag Shrivastava5
1Albert Einstein College of Medicine, Bronx, NY, USA; 2Lighthouse Guild, New York, NY, USA; 3Montefiore Medical Center, Bronx, NY, USA; 4Department of Ophthalmology, New York University Grossman School of Medicine, New York, NY, USA; 5Department of Ophthalmology and Visual Sciences, Montefiore Medical Center, Bronx, NY, USA
Correspondence: Anurag Shrivastava, Montefiore Medical Center, Glaucoma, Ophthalmology and Visual Sciences, 3400 Bainbridge Avenue, Bronx, NY, 10467, USA, Tel +1 718 920 2020, Email [email protected]
View the original paper by Dr Allen and colleagues
This is in response to the Letter to the Editor
Dear editor
We would like to thank Wijaya et al for their insightful commentary on our recently published article and for contributing to this growing area of literature. This study describes the implementation of our EMR-based referral system. As such, we employed a retrospective design to evaluate year-over-year performance. This allowed us to identify which workflow modifications yielded the greatest impact. As discussed in the manuscript, we concur that the exclusive use of Snellen acuity to determine visual impairment status remains a predictable limitation. The inability to utilize perimetric findings to flag patients with these clinically important functional deficits is a major limitation within the Epic environment. Future solutions would require integration with Zeiss Forum and/or PACS systems. We anticipate enhancing our workflow and best practice advisory (BPA) specifically to include more eligible patients should a future Epic functionality upgrade allow for this important integration.
In addition, we have actively conducted subanalyses to assess the impact of demographics, insurance carrier, primary language, and other important patient-specific factors for patients referred from our own institution. An improved understanding of barriers to access may allow us to augment our workflow to improve outcomes within our own healthcare system and beyond. Given the clinical impact of the COVID-19 pandemic during our original analysis, we concentrated our initial efforts for these subanalyses on one index year, 2023, to more precisely assess the actual impact of the referral workflow modifications. We plan to continue these analyses moving forward to better understand the longitudinal impact of our initiative.
We thank Wijaya et al again for their engagement with our work. We hope that ongoing discourse in this area will continue to enrich the literature and expand access to necessary vision rehabilitation services for patients moving forward.
Disclosure
Dr. Anurag Shrivastava is a member of the board of trustees at the Rochester Museum and Science Center and a member of the Lighthouse Guild Advisory Board Committee. The authors report no conflicts of interest in this communication.
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