 It is a distinct honor to have you all. We have our extraordinarily well-dressed, at least I can see Dr. Jacobson and Dr. Baer and their full jackets and ties today. We are very excited to have you all here. Again, we're continuing our resident research and resident QI presentations, normally done during our resident alumni day and this year adapted for virtual viewing via thanks to COVID. So with that, and I do apologize, Brad, who's up first? You're muted. Thank you for that. If we are going by the email that Megan sent out in the order, I believe it was Chris Baer, then it went me, then it went Rachel, then it went Teresa. Perfect. So it's an honor to introduce Chris Baer. He is one of our own from the University of Utah Medical School. He is an extraordinary talent on a number of levels. He has yet to share his trumpeting talents with us. Not sure that's in the plans for today. If we have any time at the end, I believe he's at home. So it's a perfect day. With that, Chris will turn the time over to you. Hey, thanks Dr. Baer. I appreciate the introduction. No trumpet playing plans for today, but maybe later. Let me get my screen shared with you all here. Okay. So really excited to be able to speak with you all today about a project that Brad, Jacobson, and I have been working on for the past year, focusing on increasing the number of underrepresented minorities in ophthalmology. Let me see here. I have no disclosures. And as we begin our discussion, it's important to define what we mean when we say underrepresented minorities or underrepresented in medicine. The AAO defines this as students who identify as black or African-American, Hispanic or Latino and Native American. The AAMC has historically had a similar definition. They've recently broadened their definition to be a little bit more inclusive. Because it's an abbreviated presentation, we're gonna move through this pretty quickly through this background information. I think we all know that diversity in medicine is important and facilitates improved health outcomes, improves patient-position relationships and expanded access to care as underrepresented minorities are more likely to practice in underserved and rural areas. In education, diversity, in ophthalmology specifically, there are well-documented disparities and outcomes between racial and ethnic minorities compared to white populations. Racial and ethnic minorities tend to have reduced access to care, higher rates of eye disease and worse overall outcomes when compared to white population. In education specifically, diversity increases cultural competency, but it's also important in attracting underrepresented minority talent. Several studies have shown that underrepresented medicine students place a greater emphasis on diversity of residents and faculty when considering a training program to attend. This is a graph showing the racial breakdown of practicing ophthalmologists and you can see that underrepresented minorities make up only about 7% of practicing ophthalmologists. Similarly, this is a graph showing the racial breakdown of ophthalmology residents and with similarly low rates of residents in underrepresented minority groups. So what can we do to change this narrative? What can we do to improve the diversity in ophthalmology here at Moran? This is a question that inspired Brad and I to start working on this project and simply stated our objective is to increase the number of underrepresented in medicine students who apply an interview at the Moran Eye Center and participate in visiting rotations with us. Our process started with a pretty expensive literature review to determine the current state of underrepresented in medicine students and ophthalmology specifically and to evaluate the strategies discussed in literature to increase engagement. This is a very complex and nuanced subject with a lot of new papers and literature being published in over the past five to seven years and we wanted to make sure that we had a solid background so we could approach this in an informed and really thoughtful way. We then met with the GME office here at the university to discuss initiatives that already have in place and to see if any of them could be implemented here with us at the Moran Eye Center. The GME office has been incredibly helpful and really great to work with. They are already working on several initiatives that are designed to increase diversity in medicine. I've listed just a few here and wanted to highlight a couple including their diversity panels which are panels of residents at the university who are in underrepresented in medicine groups who hold panel discussions during interview days to share their experiences as a resident with incoming interviewees. A couple programs, anesthesiology in particular offer scholarships to students who come to interview and some programs are targeting interest groups on campus and recruiting at schools that have higher underrepresented minority population. Now all of these are great initiatives and in long term we would like to implement several if not all of these here at Moran. However for the initial portion of our project Brad and I wanted to target an intervention that would have a more immediate impact so we established our own scholarship for students coming to Moran. So we're offering the scholarship to students who identify as underrepresented in medicine. They can receive $500 for students who participate in an away rotation with us and $300 for students to interview with us. This money can be used for food, housing, travel or whatever educational expenses the student needs appropriate. Students simply have to self identify their race on their application and submit a short statement of interest as to why they would like to come to Moran. Our initial funding has come from the ARC scholarship Brad has been generous enough to allow us to use a portion of his ARC scholarship to fund our initial offering. Now we disseminated our scholarship through a variety of channels. First we advertise it on our home Moran website. We also published this on the visiting student application service with a VSAS portal which students use to apply for away rotation. Dr. Petty was kind enough to reach out to all the program directors and let them know directly about our scholarship. And several faculty and residents have also reached out to programs directly that they have connections with to let them know about our new scholarship offer. This is a copy of the advertisement we sent out to publicize our scholarship. The scholarship was finalized and disseminated in February of this year. And at that time we initiated this. We were one of the only ophthalmology programs in the country offering direct scholarships to underrepresented minorities in this manner. Unfortunately COVID is making a lot of things difficult and it's also making it difficult to arrange away rotations. But despite that we've already received three very competitive applications from students who identify as underrepresented in medicine. One Hispanic, one Black and one Native American. We're really, really excited with these initial applications. Not only for the racial diversity they represent but also for the geographic diversity. These submissions are coming from the East Coast, from the South and even as far as our US territory. So as I mentioned Moran is one of the first programs to offer a scholarship like this. And it's exciting to be on the cutting edge of this frontier. The responses from program directors was universally positive. These are just a sampling of some comments that we received back. Many noting that they liked the idea. They were going to look into doing something similar at their institution. One person went as far as to say they were going to steal it. And another saying that they encouraged everyone to quote ride the wave and talk to leadership in their own department. A feedback's really encouraging and it's really great to see other programs are recognizing the leading role that Moran is taking in the arena of diversity in ophthalmology. However, I think a little bit more important than the comments from the program directors were the comments from the applicants themselves. One applicant stated that an aspect of Moran that drew my interest is its commitment to diversity. Another said that it's comforting to know that there are programs like Moran that are committed to increasing diversity in ophthalmology by providing support to hopeful students. And really this is the whole reason why we set up this scholarship. We want these students to recognize that Moran values diversity. We value their experiences as underrepresented minority students. And that Moran would be a safe and supportive place for them to pursue their ophthalmology residency. So what are our next steps? As I mentioned, COVID is making it difficult to arrange your way of rotation. So we're trying to do the next best thing by filming a recruitment video for interested students. Not only are we highlighting the beautiful facilities here at Moran, but we're also showcasing the talent here and interviews with faculty and staff which is really the hallmark of our residency. We want this to be a sustainable initiative that continues after Brad and I finished residency. And so we're applying for funding from the Office of Health Equity, Diversity, and Inclusion. We're planning to longitudinally track the numbers of underrepresented minority students applying and interviewing with us. And finally, we'd like to continue to work on coordinating our efforts with already existing GNV initiatives to strengthen our overall impact. So many people deserve thanks for their help with this project this far. Dr. Petty and Dr. Simpson have been instrumental in their guidance and their willingness to publicize our scholarship to the academic ophthalmology community. Dr. Poff, Sri Kaduri, Amy Armstrong, and Rob Davies are our connections in the GME office and they've been so great to work with, so, so helpful as we undertake this effort. And of course, thanks to our own Chandler Thompson who's integral in our interaction with our way students. So these are our references. I want to thank you for your attention and I'm happy to take any questions if any have arisen during my talk. Thanks. Chris, thank you so much. That is, well, Chris and Brad and really the entire residency. It is an issue that, again, is gaining prominence not just in the setting of what's happened this last week but within all of medicine. And it's interesting to see the other ophthalmology programs say things like, you know, we'll steal the idea. I mean, it really is wonderful but beyond just other ophthalmology programs, it's ENT, it's dermatology, it's general surgery, it's family medicine, really trying to broaden the diversity of their trainees and their colleagues within their specialties for many of the reasons that you outlined. And so one of the questions I have to you is as we look at the challenge of, you know, taking, you know, this very small pool in medical schools, you know, what appears to be, you know, for certain groups, you know, less than one, two percent, how can we increase the overall pool within medical schools and perhaps maybe even reach out to those in undergrad or even earlier to try and help inspire them to come into ophthalmology. Yeah, that's a great question. Oh, that's a great question. And this is a guy that said a complex and pretty nuanced issue and I think that this is going to be a long-term initiative. So a couple of things that we can talk about here. Number one, reaching these students early in their training process is a really important thing. The Academy has set up a minority mentoring program in ophthalmology which is designed just for this purpose to reach out to these students early on in their training, capture them, let them know that ophthalmology is a specialty that could be right for them and match them with mentors of similar backgrounds to them to help facilitate their interests. Implementing things like pipeline programs like the GME office here is working on, again, trying to capture the students at a younger point in their training is another thing that, you know, ideally we'd like to do kind of our long-term initiatives here. You know, there's a lot of literature out there about why there is such a lack of diversity in ophthalmology and medicine particularly, everything ranging from lack of exposure, lack of similar mentors in the field and, you know, these are things that we want to work on here and I'm glad to see that the Academy themselves have recognized and are working on doing initiatives as well. So certainly an important thing and something we're going to continue to work on. So this is Dr. Olson. Obviously this is a very important subject and one that we've grappled with for a long time. If you look at the numbers, you know, over the last 20 years, sadly, the results are kind of daunting. We've talked about this for quite a while but we haven't made a lot of progress and the numbers have been very, very flat. So we have to consider new things. I went to the, I was invited to the Horatio Alger Award ceremony back in Washington, D.C. here about eight years ago through a friend of mine who had done, who was that kind of story and to a person as they, all of them, these are people who have been quite successful who started from a very challenged background and many of them were minorities and to a person, it was often a contact either high school or just after high school that convinced them that they were actually capable of doing more. They had been, they had convinced through the awful cycles that are creating all kinds of problems like our recent race riots and rest through a cycle of things that they really couldn't do it. So if it's not on your radar screen, you won't attempt it. And it was often a teacher or a friend or someone who said, no, you can do this. And finally, you know, a light was led and they talked about the fact that they finally recognized, I can do this. And so we do need to work hard on stepping in all parts. I'm glad we're doing this. We do have a problem. We've had, we had a really good faculty member that I thought we had locked up. And the biggest concern, this was a lady of a color African-American and her big concern is the lack of much of a community here. So that's why we have to bend even further backwards to help, you know, breach that barrier because it certainly is a problem that we have to attack but appreciate this good work. This is certainly a great start. Yeah, thanks so much, Dr. Olson, I appreciate it. Thank you again, Chris. With that, we will go to Brad Jacobson, Dr. Brad Jacobson came to us by way of University of California, Irvine. He had some questionable decisions in his life. He at one point was in general surgery residency at Baylor. He was fortunately able to get a lot of good mentorship, probably some interventions from close friends and then found his way to ophthalmology eventually. He will be presenting on capillary optic disc anomaly and a family in search of it for a new genetic mutation, Dr. Jacobson. Am I unmuted and can you guys see my screen? We can see and hear you. All right, great. So yeah, thanks for the introduction, Dr. Petty. My name is Brad Jacobson, PGY3 here and I will be presenting capillary optic disc anomaly in a family in search for new genetic mutation. My research mentor for this project has been Dr. Paul Bernstein for the past two year, two and a half years we've been working on this. I have no financial disclosures, although I would like to thank the ARCS Foundation for funding most and actually all of this research thus far. And so to start off with a bit of a background, optic nerve pit is essentially an excavation of the optic disc that usually presents unilaterally in the infrotemporal quadrant of the optic nerve head. Vision loss is often secondary to serious retinal detachments and or retinoschesis. And so these photos on the right-hand side are actually a patient of Dr. Bernstein's and actually the pro band of the pedigree that I will be talking about shortly and I'm not sure if you guys all can appreciate this but there is, you can see that focal excavation in the infrotemporal quadrant of that optic nerve head and this is an actual photo of unfortunately a serious retinal detachment that occurred secondary to that optic nerve pit. And to better appreciate it, we can see down in the bottom an OCT right through that optic nerve head. You can see that large excavation and subsequent retinal detachment and fortunately this patient sought treatment fairly quickly. Dr. Bernstein performed laser and she's actually doing quite well right now. A little bit more about optic nerve pits. So there's no particular risk factors. However, there have been reports that demonstrate an autosomal dominant inheritance pattern. We actually refer to these as cavitary optic disc anomalies or CODA which describes an autosomal dominant pedigree with a range of optic nerve abnormalities from optic pits to optic nerve colobomas and morning glory disc anomalies. And so some believe actually this is a disease spectrum rather than separate disease entities. And so you can see here photos of all three of those disease entities from optic nerve pit on the lower left, right in the middle lowers optic nerve coloboma and then bottom right is the morning glory disc. And so how this all started is the patient of Dr. Bernstein, like I mentioned the pro band mentioned that other family members had eye issues like herself. She didn't know 100% sure that it was an optic nerve pit but she did mention that. And so there have been previous studies that have actually identified a copy number alteration associated with CODA specifically in chromosome 12. And so of course our preliminary genome sequencing that we performed on this pro band does not show that she has the same copy number alteration described in previous studies. And so this was really exciting and is what kind of fueled our research because essentially if there is a genetic mutation associated in this family, it would be a novel gene. And so we started off by creating a preliminary family pedigree by contacting individuals in the family. And so this really just involved me bothering the pro band, asking for all of her family's phone numbers and asking of course if it was okay that I discussed with them. And from that, we found a time in fall of 2018 now and basically flew all of these family members to the Moran Eye Center for a full workup including drawing blood samples. And so we had eight affected and 10 unaffected family members that were phenotype by visual acuity, intraocular pressure, dilated fundus exam, fundus photography and OCT. And so this is the current family tree that I have built based upon what we know so far. So I wanna walk you through this, might be something that a lot of people haven't seen in a while. So the squares represent the males, circles represent the females. The cross through the square or circle mean that the current individual is deceased. Affected individuals are highlighted in black and unaffected individuals are highlighted in white. And then of course the arrowhead there represents our pro band and Dr. Bernstein's patient. And then those that we actually examined are starred. And so those that are unstarred and white, we are unsure if they are affected or unaffected. And then the gray circle you see up above, this is presumably affected just based upon talking with family members. She developed a vision loss middle age from an unknown eye disease. And so we're assuming that she likely had optic nerve and subsequently develop some sort of serious retinal detachment and or retina schesis. And then furthermore, the individuals that are circled in red, these are individuals that we actually performed a whole genome sequencing on. And so you can see here, the pro band was of course included in this, the pro bands, two sisters, one affected, one unaffected, the pro bands mother, and then the pro bands cousin. As this study moves forward, we would of course want to examine the cousins, three daughters and son. Those are really important in genetic analysis and finding those candidate genes driving this phenotype. And so the next steps of this, so this is basically it's a multi-generation pedigree containing at least four generations of individuals affected with COTA. And as you could have seen from the pedigree, it appears that it's an autosomal dominant process. And so currently we are trying to identify candidate genes driving the optic nerve phenotype. And we're working closely with being from the bioinformatics department at the Huntsman Cancer Center to help us out with this. And once candidate genes are identified, analysis will begin on the entire pedigree. And this basically is going to involve looking at effective individuals and common genes and trying to narrow this down. It's a really big project when you're dealing with whole genome sequencing, but we're really excited. And so far we have some promising results, but we're still waiting from the full report from the bioinformatics department. And some limitations of this study, obviously the number of individuals within the pedigree, we have a significant amount compared to other studies, but still the more effective individuals would allow for a more thorough analysis. And we don't necessarily know the natural history of this disease. And what I mean by that is the age of onset in previous studies, there were some individuals that actually had the copy number alteration associated with COTA, but did not express the phenotype. And so once again, some of these unaffected individuals might just, they might have the genotype, but not yet have expressed the phenotype. And so I'd like to give special thanks, of course, to Dr. Bernstein, my research mentor, Barbara and Kellyanne from the research department have been phenomenal and just helping me contact these individuals, helping me build the pedigree. Denise Morgan, who was working previously with Dr. DeAngeles, who's now working with Dr. Huang has been instrumental. And then of course, Dr. Huang, Musa being and Dr. DeAngeles as well have been really helpful in this. And so these are my references for the presentation and at this time I will take any questions, comments or concerns. Thank you, Brad. Dr. Jacobson, I don't see any comments or questions coming up on the chat, but certainly someone chime in if there are any. Brad, one question I had is, again, I may have missed it, I assume you use the Utah population database for this family or did you, were you able to pedigree this family via other means? So the way this actually happened is the pro band of the family, Dr. Bernstein's patient, it came in and she had this optic nerve pit and just kind of upon further interviewing and Dr. Bernstein might know a little bit more, this was before my time, but basically upon further investigating, she just mentioned that she had other family members. So we really haven't used any Utah database at this point. We're really focusing on the pedigree of this specific family. And most of them actually are from or live in Idaho. Yeah, so this is Paul Bernstein here. Whenever I have a patient like this come in. Sorry. Whenever I have a patient like this come in, I just take a family history and a lot of these people know their families with regard to going through the Utah population database, that is a way to be doing this, but you have to have good quality coding of optic nerve pit, which we could be trying, but that would be something to look at in the future. You'd find other families with this and then try to build out families. But this is old fashioned genetics that we're doing right here. Thank you, Dr. Bernstein. And thank you, Dr. Jacobson. Dr. Olson did note nice work in the chat and comments. That was wonderful. So moving on to our next speaker. Sorry, was there a comment? I think it was just Paul, I think it was just you. So our next speaker is Dr. Rachel Patel. She came to us from her medical school at University of Massachusetts. Her talk is implementation of a CPRS-based electronic medical record at Salt Lake City VA Ophthalmology Clinic. Clearly something near and dear to my heart. There's actually a number of extraordinary lessons learned throughout this. So without further ado, Dr. Patel. Thanks very much. Okay, so as many of you are aware of, I'm gonna be talking about a topic that a lot of you guys have worked with and are familiar with, but just to catch everyone up to date. It is about implementing our CPRS-based EMR at the Ophthalmology Clinic at the VA. So just a brief point about where we started from. We have for many decades used paper charts that have been filled out by a technician who copies over all of their ocular history, all of their ocular surgeries, their medications, turns it over to a lineup where it is drawn from by the residents who are in clinic that day. The residents fill out the remainder of the chart. They then have the attending sign the sheet and then following that, the chart is sent for scanning, which after a couple of days is uploaded into VISTA imaging. This is a sub application of CPRS and when you have a bunch of ophthalmology notes, it can look a little bit like this. So there were several issues with paper charts, including of course just the requirement for manual transcription of all this prior information, which was not only tedious, but also was prone to permitting errors to be copied forward. There was a little bit of difficulty trending intraocular pressure or visual acuity over time to get more than one previous eye vital. It required dozens of clicks. There is a slightly smaller area for documenting assessment and plan, which meant that some were a little bit more abbreviated than others. There were more lost or missing charts than should be considered acceptable in a clinic. And the ones that did get uploaded would be delayed by a day or several days before they were properly uploaded. It also was more of a challenge for other services to find our notes in VISTA imaging and to be able to interpret them. And while some people thought that handwriting was the main reason why this project went ahead, it wasn't really, but it was certainly some of an issue. So in creating a solution for this, the EMR was designed purely within what CPRS offers. CPRS is the program that the remainder of the clinics at the VA, other than ophthalmology, have been using. So we designed templates, including clinic templates and post-operative templates that can look something like this, where there is spots for information entering about a patient that mostly correlates with what was on the paper chart in the past. We also created additional shared templates that function similar to dot-phrases in EPIC, which can be dragged into a patient's chart depending on what is required for that visit. Now, because the creation of electronic notes the first time that a patient comes in is quite time consuming, we adopted a system where pre-charts were created prior to the day of clinic and those were saved into the medical record. Then on the day of clinic, technicians will create a clinical note separately based on the pre-charts, fill out all their screening information and then they route the chart to one of the residents who's in the clinic. And then we still used paper trackers, however, to mark where the patients were throughout the visit to keep track of things. So as for the early transition itself, this was implemented in the last two weeks of December of 2019. At that time, we had cut clinics down to half volume and then transitioned to full clinics in early January of 2020. In January, there was one half day where one of the clinics was reverted back to paper charts due to an overwhelming clinical volume. The remainder of the days that we've been working with it have really been using the electronic medical record. And when I refer to the transition, however, I want to say that it's not just those first two weeks that this has really been an ongoing process and there have been multiple rounds of template and structural updates based on people's feedback. So in terms of seeking how to evaluate this implementation and how it went, we have been open to receiving written and verbal feedback from anyone who has worked with the EMR over the past few months. And in addition to that, this past month, I sat down with any technicians and residents who were interested in talking and had an eight point question interview about their experiences with the EMR and where we can go from here. Now, what I'm gonna be talking about from here on out will be based mostly on these interviews that were conducted. So overall, the beneficial outcomes were fairly universally agreed upon by most people in the fact that these notes were easier to access. It was a lot easier to trend eye vitals, copying forward some information, especially complex histories and plans could save time. There wasn't a delay due to waiting for notes to be scanned in. Other services were more easily able to access and understand our notes and there were likely fewer lost notes. One more racial concern, but also something that was brought up by several people was that this could potentially improve efficiency but that remains to be seen. Meanwhile, the challenges that were faced due to this transition were more complex and we created a long enough list that I could talk for hours about that. So instead I wanted to spotlight just a few issues that we can talk about today. First off, it's known that the EMR has contributed to delays in clinic. Naturally, part of this was due to learning a new system, learning a new EMR and flow. At the beginning, especially, there were documented wait times of up to three to four hours for patients to be seen by a physician. But this continued when there were just especially busy clinics later on even after the initial transition or when there were multiple add-ons in clinic. Some have suggested that having a paper tracker created the temptation of writing down information on there to be transcribed later, which of course does take more time in the long run. And the clinical delays that were directly caused by the EMR were also compounded by a quite flawed scheduling system of which I won't get into in detail right now but does have several issues including that it requires frequent overbook orders for even routine care to be scheduled in a timely fashion and also generates the possibility for multiple overbook spots early each morning and each afternoon so that right after that patients are going to be, I can't all be teched up at once and are going to be waiting a long time. Now, the impact of clinical delays we know does decrease patient satisfaction but also is not kosher nowadays due to increased risk of COVID exposure while waiting in a waiting room, especially in a vulnerable population. Next, we learned the importance of chart consistency and the challenges of maintaining that. Many people did say that having templates and consistent documentation was helpful. For example, this was one example of what we use in terms of Oklahoma summary information and people have brought up that having all the information in one spot can certainly aid in clinical decision making as well as teaching us as junior residents what's important to focus on when taking care of these patients. However, the problem is that keeping templates up to date takes time, takes consistency which is not always possible in really busy clinics and it can be tricky when a patient doesn't see the same resident provider at each visit. Of course, there are also limitations inherent to CPRS itself and these include the fact that notes are not editable once they're signed, that an all addenda appear at the bottom, that notes in progress can be only viewed or edited by one designated resident or an attending at a time which can make it cumbersome for residents to switch which person will be seeing a patient that day or if a patient needs to go back to the technician to have further testing or work up after the note's been signed over. It also is naturally a little bit unwieldy to toggle between both CPRS and VISTA imaging to look at previous information as well as sites to look at any imaging. And a smaller issue but one just to note that pre charts do remain a part of the permanent medical record and uncommonly but has happened. This has caused some confusion with other specialties who do view the charts and are confused as to why they're not filled out especially if the actual encounter didn't occur. So in asking the people who I interviewed does this transition in your opinion help or hurt patient care? There actually was a fairly even split between people who felt, yes, it had a positive impact those who felt it had no impact on patient care and those who felt like it was too early to tell. The jury is still out. So as I mentioned, this is an ongoing process. Some things that we're looking to implement in the near future include the development of short checklist for technicians and residents to ensure consistency over time and the acquisition of a couple more double monitors for clinic rooms to be able to navigate the computer system a little bit better. And also something that's been going on for the past several months has been the process of looking ahead at each clinic schedule and deciding which patients need to be seen. This was done exclusively for minimizing COVID exposure and the protocols that the VA has put in place. But I bring it up because it has had an impact on the use of the EMR. And to mention just a few more big picture issues that are changes that are not readily implemented, it would be great to get rid of a CPRS and have it just be a different system or any system that involves signing over notes to a pool of residents, kind of similar to how we did on paper charts. And as people know, CERNR is contracted with the VA to generate a new EMR. But the projected goal live for the Salt Lake Clinic is no sooner than 2027. So we do have several years left with this system. Also having additional exam rooms would help and having all the technicians have their own workup room as well as improving clinic flow. For example, for patients need to be dilated and wait on that. And also changing the scheduling system could allow for better flow and lessen the delays that are happening in the clinic. So I do want to emphasize that this was by no means a solo project. This was really a collaborative effort by so many people. Rachel Simpson in particular has been the leader and the voice on this since day one, but also all of the technicians and residents and fellows, even those who had, did not sign up for this in the first place, have put in countless hours of work pre-charting as well as troubleshooting and ironing out flaws during clinic. And a lot of people have spent a ton more time there recently than I have. And so I just want to say thank you, thank you for what you do. It does not go unappreciated and I'm happy to hear any feedback or discussion that you have today. With that, I would like to open it up for questions. I put some questions here that people can think about in terms of what they wanted to discuss or bring up or suggest. I also would mention that I did not address COVID and the impact that it has had on VA clinic in particular. It's kind of hard to separate because looking back kind of ironically, the EMR and COVID came into the world around exactly the same time. And so that has made it a little bit tricky to parse out the separate changes and impacts that they've had, but I've tried to do that as best as possible so that we can evaluate to this as a separate standing system that hopefully will outlast the coronavirus. And so with that, I would like to take any questions that people might have. So this is Dr. Olson-Rachael. You certainly raise an important issue and that is how we can improve the utility of our electronic medical record. There was a lot of promises and thoughts about how this could help us. I think it's definitely helped in regards to things like having a legible record and one that's available much more often than the paper. It's certainly more thorough. It has led to brand new problems, over documentation, being able just to forward a lot of very famous stories about that that I won't go into any detail. But the utility of the system is still quite complicated. And I think anything like this is certainly as helpful, but the big problem I think we've had, and I'm not a guru on this, but I got a son who's a medical informaticist who's worked with most of the big companies and understands is that a lot of these are being written mainly to fit with the billing side and not the utility side. And not that that's unimportant. It's certainly, it's important to have that, to make sure there's all this documentation. And a lot of it is based upon very, very old technology. The infrastructure for the Epic system is essentially 16-bit technology, robust, but still, not what we're used to in other areas. So I'm still very hopeful that there've been attempts to start up, but that a Google or an Apple or some of these others who worked at it, it's the bureaucracy that makes it difficult. And the relative monopoly that Epic has as well, that makes it difficult to have something that's as simple as we're used to on our iPhone. And that is very intuitive. And the other problem is that doctors don't get involved much in putting these things together. They're largely done as my son loves to say, computer nerds for computer nerds. And they don't necessarily think the same way. I mean, they need to be there, but his suggestion is they don't necessarily really listen. And that's why for those of us who get frustrated where you're used to a location and then suddenly it changes to a different location. And it makes no sense why somebody like me and my son will say, oh, well, I see this, that this is closer to this than this. And it saves a little motion on your cursor in order to do that, but it's what drives a lot of people, baddie. A lot of time is spent. All the studies that have been done to date show that the marked increase in burnout happened with the onset of electronic medical records. I think that that's getting better, but it still is actually a major stressor in the system. It's not going away. I mean, we've got to have it. It's not very searchable, also a problem. And Epic often has not made it easy for others to utilize it. Cerners number two, they're trying to catch up, but their underlying system that they've put together is dramatically more difficult to work with than Epic is. So we'll just see how it goes. I still think we'll see a big champion come in with a new platform based upon the latest technology. And this whole thing will just change almost overnight. But for a while, we've got to limp along with the tools we have, sadly. Thank you, Dr. Olson. Just one comment, and then Dr. Kenscher had a comment question before Terry gives her talk. Really, I think one of the questions you're really getting at is, are we in a better place now? And does the accessibility and the ability to read the electronic medical record for us and others outweigh the convenience and efficiencies of the paper chart? And I really, I think you can say yes or no, depending on which metric you really want to focus on and what you're valuing in that. In the end, absolutely, I feel like this is a step in the right direction. It doesn't mean it's not without challenges. Burnout being one real one. Dr. Bear and Dr. Katherine Hu are two who really felt a big brunt of this in the transition. And that was that a time in the residency when they wanted to be studying pro-keps and other things. And not only is the transition challenging, but just the implementation and use of it. So looking forward, we certainly will have another transition coming at some point with Cerner at the VA. We have modifications we are making at the VA in terms of patient flow, patient volumes with COVID. And in truth, we just, frankly, have more patients to see than we can with our current resources, as you pointed out. And that really becomes our challenge. So as soon as this is over, I'll be taking the recording from Ethan and sending this talk over to VA leadership. With that, Dr. Gensher, go ahead and make your comment. And then we'll go to Dr. Long. Thanks, Dr. Patel, a really great presentation. I was just curious, because I'm not familiar with the literature in this area, how when people are undertaking switching over to a EMR or some kind of transition like this, what are the ways that we can actually see how these interventions affect patient outcomes? Do you have any thoughts about that? And if not, that's OK. That is a good question. So this was something that I always talked about very briefly before the implementation, but mostly afterwards. And the thoughts have been that monitoring for outcomes based on what we wanted to see, such as losing fewer charts, potentially how much time does people spend in front of a computer versus with a patient, all of those would involve tracking something that would fall on the residents themselves to monitor. And in terms of asking people to add to their responsibilities of what to do in clinic, we do not feel like taking those criteria as an additional burden was worthwhile. And therefore, the monitoring per se has been more in terms of trying to receive feedback from all of you guys. That being said, if other people have ideas with how to try to catch these things or evaluate this process, then I'm definitely open to suggestions. Thank you again, Dr. Patel. And if you would stop sharing your screen, we'll move on to Dr. Long. Dr. Long's been a joy to have in the program. She comes to us by way of University of Missouri. Her talk today is on fluorescence lifetime imaging ophthalmoscopy in patients with X-League linked retin eskises and other foveal eskises. Dr. Long. OK, good morning, everyone. I apologize. I'm not as spiffily dressed as my co-residents. I am headed to the OR directly after this with Dr. Hartnett, who's been one of my mentors on this. And she's sorry that she can't be heard today, but she's taking care of patients at primary children. So I'm happy to discuss with you some findings that we have involving flio and X-link retin eskises and other foveal eskises today. I have no disclosures. So first, I want to talk about X-link retin eskises. We know that it's an inherited retinal disease. It has mutations in the RS1 gene, which encodes a protein retin eskisen, which is found on the X chromosome. And therefore, it does show X-linked inheritance. And this protein is involved in intracellular adhesions and retinal cellular organization. The prevalence of the disease is somewhere between 1 in 15,000 and 1 in 30,000 individuals. It has complete penetrance and variable expressivity. But the phenotype can be markedly variable, even within the same genotype. And so oftentimes, these children will, usually males, will come into, often males, will come into clinic. During their school age years, they'll have poor vision. Or they may even present earlier in life with an infancy, with nystagmus, turbismus, hyperopia, phovial ectopia, and vitreous hemorrhage, and even retinal detachment. And we know from their exam that 98% to 100% of them do have phovial schesis, which, if you look under a red-free filter, you can see this spoke wheel pattern radiating from the phobia. And then greater than 50% of them, in addition, also have peripheral schesis. So not only can their visual acuity, depending on how early they present, be highly varied. They can be as vision as good as 2020. But also, as vision as poor as no light perception, their clinical course can be complicated by vitreous hemorrhage and retinal detachment and require many invasive retinal surgeries when they're very young. So quite a challenging disease process. So what is flio? I won't belabor this, since we have had multiple tox this year. But it is a quantitative imaging procedure. And it measures the fluorescence lifetime of fluorophores. So essentially, you take a polstyled laser at 472 nanometers, shine it into the eye. And then those fluorophores, which are fluorescent chemical compounds, re-emit photons. And then the machine will measure the fluorescence intensity. That's the quantity of photons in each pixel. And it also measures how long the retinal fluorophore glows after excitation. And this is known as the fluorescence lifetime. And so it creates these absolutely beautiful photos that we have seen, or absolutely beautiful images that we've seen and had the benefit of studying here at Moran quite intensively. And so you can see what we would see for a normal, healthy control. I'm going to be discussing retinoskises here. But we have done a lot of research on macular degeneration, Mac-Tel, Starr-Garth disease. And here's just some other examples. So it's a really unique way and beautiful way to image pathology in the retina. So our research project was a cross-sectional study. And it was comparing flioimaging in patients with X-link schesis and other foveal schesis to H-max match controls. We took the Funnest Auto fluorescence lifetimes in a 30-degree retinal field. And we detected these in two spectral channels, the short spectral channel, which was 498 to 560 nanometers, and the long spectral channel, which was 560 to 720 nanometers. And then we looked at amplitude-weighted mean fluorescent times. We calculated these. And we based this on the ET DRS grid. And so we measured these in a central subfield, inner ring and outer ring, and compared these to the healthy controls. We had patients that were recruited from Dr. Hartnett's clinic. So we had 11 male patients. We had seven of them that had confirmed mutations in RS1. Three patients refused genetic testing. One of these patients did have a family member with confirmed RS1 mutations. And the other two clinically looked like retina schesis. The age of the patients ranged from seven to 26 years. And we did have one patient with Wagner syndrome, which came out later. So he is included in this data set. So I think that potentially can skew the results. And we can talk about that a little bit later. And then we compared these to 11 age-matched controls. We also only included one eye for analysis. So here you can see a list of my patients, their ages, and then what their genetic testing was. And then the status of their lens and just some information about the image quality that we had as well. So looking at the results, it was really exciting. So the mean flio lifetimes were significantly different between the control and the X-linked retina schesis patients or other phobial schesis in the central subfield based on the standard ETDRS grid. But they weren't different in the inner ring or the outer ring. And so here you can see an example of healthy. And then also with schesis. But I wanted to illustrate a few more things, looking at more qualitative data. So when you look at fundus autofluorescence for healthy individuals, they have this hypo-autofluorescence spot in the center that you can see in the short spectral and long spectral channels. And in retina schesis, the fovea where we typically would have this hypo-autofluorescence spot is disrupted with these intermittent areas of hyper-autofluorescence. And it's interesting that these hyper-fluorescent areas in the short spectral channel correspond with hypo-fluorescent areas in the long spectral channels. You can almost see a reversal. And then just looking at the flio lifetimes in further detail, the healthy controls, we know that in the fovea, we typically see the shortest lifetimes or the warmer colors. The fundus, we see the intermediate lifetimes or the middle of the rainbow. And then around the optic nerve, we see the longest lifetimes or the coolest colors. And in retina schesis, these short lifetimes are disrupted. Other things moving on here is really unique, we think, to retina schesis, in addition to the hyper and hypo-autofluorescence matching that we can see in the autofluorescence channels. The foveas of these patients tended to have this spoke wheel type pattern, which is really unique, and we didn't anticipate this. And it's also different from other forms of schesis. So within the short spectral channel, you can see here the short-fiel lifetimes correspond to hyper-fluorescence, hyper-autofluorescence intensity. So this basically orange spot correlates to this brighter white spot. And in the long spectral channel, it's the opposite. So we have the hypo-autofluorescence corresponding to the short spectral channel. So just to illustrate this, it's kind of exactly what we're imaging together. The other thing that we looked at was the cystic spaces. And so if you have looked at an OCT from a patient with retina schesis, you know that they have schesis in the nerve fiber layer, and they have cystic spaces. And we essentially looked at these. I don't have the chart on my presentation today, but there was a significant difference in flio lifetimes between the cysts, which are the hyper-fluorescent areas in the long spectral channel and adjacent spaces. And these flio lifetimes were significantly longer. So in these spaces of green and blue and cooler colors, the cysts show flio lifetimes around 100 picoseconds and 160 picoseconds in the short and long spectral channels, respectively. And so this is a little bit longer than the adjacent areas. So what we are learning is that flio is able to differentiate these findings, and we necessarily don't know what it means yet. So I think some strengths of this I think above my project is that flio presents a unique imaging findings in inherited retinal diseases. We've learned this from other research that we've done here, too. And I think this is also true in x-linked retina schesis. It can differentiate the cystic spaces between the spectral channels. And I think another strength of the project is that it includes mostly children. So adult patients in flio can show other diseases later in life. And so it was unique that we have such a young population. Some limitations, small study size. Our patient with Wagner's was included in this data set. And so that may have skewed the results, but we're looking at going back and recruiting more patients and also potentially comparing one eye or the other one patient. And then we don't have genetic testing on all patients. And then we also have limited longitudinal follow-up. So around four of our patients, we had followed up at one year. And it would be very interesting to see these patients after several years to see how their flio changes and also how their schesis progresses. And the interesting thing is that flio is clearly sensitive enough to pick up something in these cystic spaces that is unique to x-linked retina schesis. And we don't know what is in the cystic spaces. It's been hypothesized that it is related to some sort of proteinaceous substance. And we think that that may be related, but we're not sure. So it's an interesting place for further research. So in conclusion, flio shows a characteristic pattern of spoke wheel shape distortion in flio lifetimes in the phobia. And this differs from inherited retinal diseases. It also, within the schesis, says that lifetimes are longer compared to adjacent areas. And then really, there's a lot more still to learn from this process. I think for the future, I would like to add more patients. So if any of our pediatric ophthalmology clinicians are still here, we would love to see patients, if they image them for flio, if you feel like they would be appropriate. They do, I believe, have to be older than seven years old. I think it would be interesting to do some statistics to analyze both eyes. And then I would also like to compare larger data sets to other processes. So just this week, we actually looked at retinitis pigmentosa, which has a similar pathology when you look on OCT, if you think about the presence of cystoid macular edema, but also distinctly different pathology. And there are some things where the retinitis pigmentosa patients are not different from normal, but there is a slight difference between RP and schesis. And so I think we may need more numbers to see if this is statistically significant. And here are references. So I really want to say thank you so much Dr. Hartnett and Dr. Bernstein. And also to these three girls who are known as Team Flio. So Lydia Sallar, Alex Vitale, and Natalie Motorsitzke. It's a really wonderful thing to be at a place like the Moran where people are willing to share in their academic endeavors so that you can learn. And have help and learn about something new. And with that, I will take any questions. Thank you so much, Teresa. We actually will take some questions. But given that we are up against time, I do just want to thank everyone for attending, for anyone that needs to leave. That the meeting will officially end now. A couple of questions coming through you can see in the chat there, Teresa. I will also unmute Lydia as well. And I'll unmute you, Chris, so that you can comment on the answer to the question, do the Flio lifetime patterns in a normal retina stay static over time, or do they change and shift with age? Teresa, you can take a crack at that, or Paul can unmute himself. And Lydia can also answer as well. Thank you, everyone. Yes. So from what we know, the lifetimes do prolong with age. I am just new in my Flio learning, so I will turn it over to the experts in the field. So Dr. Bernstein and Dr. Sauer, who are with us, please feel free to chime in. Hi, this is Lydia. I am. So we just have a study that is about to be published, looking a little bit more on the age effect of Flio. And what we have found is that the two channels change differently with age. And we believe that the long spectral channel, so the second channel is really impacted by the lifelong accumulation of lipofustin, whereas the first channel kind of stays the same until the age of about 35. And then we see changes that we think are related to the lens. But it does prolong with age a little bit over time. I hope that answers the question. And then the second question from Dr. Bernstein. I can go ahead and answer. Do we routinely get macular pigment on these study patients? This could help sort out what's happening at the phobia. So thank you, Dr. Bernstein. We are actually looking at this. So I looked this week, and we now have we've actually added a few more species patients that we're going to recalculate the data for. And six of the 12 have macular pigment. And so we are hoping to also look at this and include that in our final analysis. Very good. Yeah, I think that's important. Yeah, and just this is Lydia one more time. I just saw in the chat that if it is predictable, it is somewhat predictable, but not entirely yet. We're trying to quantify the lens impact because patients that develop cataract that can be more or less strong. So that's not quite as predictable. And we're trying to kind of find a solution for that. All right, Dr. Penny, I think we are good to go. Thank you so much, everyone. It was a good day.