Appl Clin Inform 2015; 06(03): 478-487
DOI: 10.4338/ACI-2015-03-RA-0028
Research Article
Schattauer GmbH

eHealth 2015 Special Issue: Impact of Electronic Health Records on the Completeness of Clinical Documentation Generated during Diabetic Retinopathy Consultations

C. Mitsch
1   Medical University of Vienna, Department of Ophthalmology and Optometrics, Vienna, Austria
,
P. Huber
1   Medical University of Vienna, Department of Ophthalmology and Optometrics, Vienna, Austria
,
K. Kriechbaum
1   Medical University of Vienna, Department of Ophthalmology and Optometrics, Vienna, Austria
,
C. Scholda
1   Medical University of Vienna, Department of Ophthalmology and Optometrics, Vienna, Austria
,
G. Duftschmid
2   Medical University of Vienna, Center for Medical Statistics, Informatics, and Intelligent Systems, Vienna, Austria
,
T. Wrba
2   Medical University of Vienna, Center for Medical Statistics, Informatics, and Intelligent Systems, Vienna, Austria
,
U. Schmidt-Erfurth
1   Medical University of Vienna, Department of Ophthalmology and Optometrics, Vienna, Austria
› Institutsangaben
Weitere Informationen

Publikationsverlauf

received: 31. März 2015

accepted in revised form: 11. Mai 2015

Publikationsdatum:
19. Dezember 2017 (online)

Summary

Background: Two years ago, the Diabetic Retinopathy (DRP) and Traumatology clinic of the Department of Ophthalmology and Optometrics at the Medical University of Vienna, Austria switched from paper-based to electronic health records. A customized electronic health record system (EHR-S) was implemented.

Objectives: To assess the completeness of information documented electronically compared with manually during patient visits.

Methods: The Preferred Practice Pattern for Diabetic Retinopathy published by the American Academy of Ophthalmology was distilled into a list of medical features grouped into categories to be assessed and documented during the management of patients with DRP. The last seventy paper-based records and all electronic records generated since the switch were analyzed and graded for the presence of features on the list and the resulting scores compared.

Results: In all categories, clinical documentation was more complete in the EHR group.

Conclusions: In our setting, the implementation of an EHR-S showed a statistically significant positive impact on documentation completeness.

Citation: Mitsch C, Huber P, Kriechbaum K, Scholda C, Duftschmid G, Wrba T, Schmidt-Erfurth U. Impact of Electronic Health Records on the Completeness of Clinical Documentation Generated during Diabetic Retinopathy Consultations. Appl Clin Inform 2015; 6: 478–487

http://dx.doi.org/10.4338/ACI-2015-03-RA-0028