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

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

Keywords

Ophthalmology - Electronic health records and systems - Testing and evaluation - Encounter notes - Care records

 

Conflict of Interest

The authors declare that they have no conflicts of interest in the research.

• References

• 1 Greenes RA. Medical Informatics. JAMA. American Medical Association 1990; 263 (08) 1114.
• 2 Richard S, Dick Elaine B, Steen, and Don E. Detmer, Editors; Committee on Improving the Patient Record I of M. The Computer-Based Patient Record: An Essential Technology for Health Care. Revised Edition Natl Acad Press; 1997
• 3 Furukawa MF, King J, Patel V, Hsiao C-J, Adler-Milstein J, Jha AK. Despite substantial progress In EHR adoption, health information exchange and patient engagement remain low in office settings. Health Aff (Millwood) 2014; 9: 1672-1679.
• 4 Grabenbauer L, Skinner a, Windle J. Electronic Health Record Adoption –Maybe It’s not about the Money. Appl Clin Inform 2011; 2 (04) 4604-4671.
• 5 Hoerbst a, Ammenwerth E. Electronic health records: A systematic review on quality requirements. Methods Inf Med 2010; 49 (04) 320-336.
• 6 Katzer R, Barton DJ, Adelman S, Clark S, Seaman EL, Hudson KB. Impact of implementing an EMR on physical exam documentation by ambulance personnel. Appl Clin Inform 2012; 3 (03) 301-308.
• 7 Sanders DS, Lattin DJ, Read-Brown S, Tu DC, Wilson DJ, Hwang TS, Morrison JC, Yackel TR, Chiang MF. Electronic health record systems in ophthalmology: impact on clinical documentation. Ophthalmology 2013; 120 (09) 1745-1755.
• 8 Pandit RR, Boland M V. The impact of an electronic health record transition on a glaucoma subspecialty practice. Ophthalmology 2013; 120 (04) 753-760.
• 9 Sanders DS, Read-Brown S, Tu DC, Lambert WE, Choi D, Almario BM, Yackel TR, Brown AS, Chiang MF. Impact of an electronic health record operating room management system in ophthalmology on documentation time, surgical volume, and staffing. JAMA Ophthalmol 2014; 132 (05) 586-592.
• 10 Dorda W, Wrba T, Duftschmid G, Sachs P, Gall W, Rehnelt C, Boldt G, Premauer W. ArchiMed: a medical information and retrieval system. Methods Inf Med 1999; 38 (01) 16-24.
• 11 American Academy of Ophthalmology Retina/Vitreous Panel.. Preferred Practice Pattern (R) Guidelines. Diabetic Retinopathy. San Francisco, CA: American Academy of Ophthalmology; 2014. Available from: www.aao.org/ppp