Electronic Health Record Systems in Ophthalmology

Introducing a digital emergency obstetric and newborn care register for indoor obstetric patient management: An implementation research in selected public health care facilities of Bangladesh

Background

Digital health records have emerged as vital tools for improving health care delivery and patient data management. Acknowledging the gaps in data recording by a paper-based register, the emergency obstetric and newborn care (EmONC) register used in the labour ward was digitised. In this study, we aimed to assess the implementation outcome of the digital register in selected public health care facilities in Bangladesh.

Methods

Extensive collaboration with stakeholders facilitated the development of an android-based electronic register from the paper-based register in the labour rooms of the selected district and sub-district level public health facilities of Bangladesh. We conducted a study to assess the implementation outcome of introducing the digital EmONC register in the labour ward.

Results

The digital register demonstrated high usability with a score of 83.7 according to the system usability scale, and health care providers found it highly acceptable, with an average score exceeding 95% using the technology acceptance model. The adoption rate reached an impressive 98% (95% confidence interval (CI) = 98-99), and fidelity stood at 90% (95% CI = 88-91) in the digital register, encompassing more than 80% of data elements. Notably, fidelity increased significantly over the implementation period of six months. The digital system proved a high utility rate of 89% (95% CI = 88-91), and all outcome variables exceeded the predefined benchmark.

Conclusions

The implementation outcome assessment underscores the potential of the digital register to enhance maternal and newborn health care in Bangladesh. Its user-friendliness, improved data completeness, and high adoption rates indicate its capacity to streamline health care data management and improve the quality of care.

A prototype protocol for evaluating the real-world data set using a structured electronic health record in glaucoma

PURPOSE

As the first step in monitoring and evaluating day-to-day glaucoma care, this study reports all real-world data recorded during the first full year after the implementation of a prototype for glaucoma-specific structured electronic healthcare record (EHR).

METHODS

In 2019, 4618 patients visited Tays Medical Glaucoma Clinic at Tays Eye Centre, Tampere University Hospital, Finland, that serves a population of 0.53 M. Patient data were entered into a glaucoma-specific EHR by trained nurses to be checked by glaucoma specialists. Tays Eye Centre follows the Finnish Current Care Guideline for glaucoma in which glaucoma is defined using a '2 out of 3' rule, that is, ≥2 findings evaluated as glaucomatous in optic nerve head (ONH), retinal nerve fibre layer (RNFL) and visual field (VF).

RESULTS

The clinical evaluations of ONH, RNFL and VF were recorded in 95%-100% of all eyes. ONH was evaluated as glaucomatous more often (44%) than RNFL (33%) and VF tests (30%). Progressive changes in any of the three tests were recorded in 35% of the '≥2/3 glaucoma group' compared to 2%-9% in the other groups. The mean IOP at visit was 15 mmHg. The mean target IOP was 17 mmHg, and it was recorded in 94% of eyes.

CONCLUSION

The developed structured data presentation enables comparisons between different population-based real-world glaucoma data sets and glaucoma clinics. Compared to a data set from the UK, the proportion of glaucoma suspicion-related visits was smaller in Tays Eye Centre and test intervals were longer.

Analysis on the completeness of case records of patients with penetrating ocular trauma following a multimodal intervention

Purpose

To describe the process development of a multimodal intervention and the pre- and postintervention results on the completeness of case records of patients with penetrating ocular trauma in a high-volume tertiary eye care hospital in south India.

Methods

A multimodal intervention including an objective-validated case sheet template, an education program, a physical template case record reminder, a continuous near-real time audit process, and a feedback system was developed. Analysis on the completeness of the case records of patients with ocular trauma from October 2020 to December 2020 (preintervention) and from January 2021 to March 2021 (postintervention) was performed. These case records and the personnel involved in the documentation, were given scores based on the scores assigned to the subsections of the validated template case sheet. The mean total score of the case records and of the personnel involved were analyzed.

Results

One hundred and eleven case records of patients with ocular trauma who underwent primary wound repair were included in the study. Of these 111 case records, 46 belonged to preintervention group and 65 belonged to postintervention group. The mean total score for preintervention group during the study period was 57.93 ± 24 out of 100 and for postintervention group was 99.07 ± 4.49 out of 100. The temporal trend of postintervention group showed a consistent improvement every month (97.14, 100,100) during the 3-month study period. Postintervention improvement was noted in all the sections of case records completed by both fellows and consultants.

Conclusion

A sustained improvement in ocular trauma case record documentation among all levels of medical professionals was noted following the five-component multimodal intervention.

Electronic Health Records in Ophthalmology: Source and Method of Documentation

PURPOSE

This study analyzed and quantified the sources of electronic health record (EHR) text documentation in ophthalmology progress notes.

DESIGN

EHR documentation review and analysis.

METHODS

Setting: a single academic ophthalmology department.

STUDY POPULATION

a cohort study conducted between November 1, 2016, and December 31, 2018, using secondary EHR data and a follow-up manual review of a random samples. The cohort study included 123,274 progress notes documented by 42 attending providers. These notes were for patients with the 5 most common primary International Statistical Classification of Diseases and Related Health Problems, version 10, parent codes for each provider. For the manual review, 120 notes from 8 providers were randomly sampled. Main outcome measurements were characters or number of words in each note categorized by attribution source, author type, and time of creation.

RESULTS

Imported text entries made up the majority of text in new and return patients, 2,978 characters (77%) and 3,612 characters (91%). Support staff members authored substantial portions of notes; 3,024 characters (68%) of new patient notes, 3,953 characters (83%) of return patient notes. Finally, providers completed large amounts of documentation after clinical visits: 135 words (35%) of new patient notes, 102 words (27%) of return patient notes.

CONCLUSIONS

EHR documentation consists largely of imported text, is often authored by support staff, and is often written after the end of a visit. These findings raise questions about documentation accuracy and utility and may have implications for quality of care and patient-provider relationships.

Anterior Chamber Angle Evaluation Using Gonioscopy: Consistency and Agreement between Optometrists and Ophthalmologists

SIGNIFICANCE

In our intermediate-tier glaucoma care clinic, we demonstrate fair to moderate agreement in gonioscopy examination between optometrists and ophthalmologists, but excellent agreement when considering open versus closed angles. We highlight the need for increased consistency in the evaluation and recording of angle status using gonioscopy.

PURPOSE

The consistency of gonioscopy results obtained by different clinicians is not known but is important in moving toward practice modalities such as telemedicine and collaborative care clinics. The purpose of this study was to evaluate the description and concordance of gonioscopy results among different practitioners.

METHODS

The medical records of 101 patients seen within a collaborative care glaucoma clinic who had undergone gonioscopic assessment by two clinicians (one optometrist and either one general ophthalmologist [n = 50] or one glaucoma specialist [n = 51]) were reviewed. The gonioscopy records were evaluated for their descriptions of deepest structure seen, trabecular pigmentation, iris configuration, and other features. These were compared between clinicians (optometrist vs. ophthalmologist) and against the final diagnosis.

RESULTS

Overall, 51.9 and 59.8% of angles were graded identically in terms of deepest visible structure when comparing between optometrist versus general ophthalmologist and optometrist versus glaucoma specialist, respectively. The concordance increased when considering ±1 of the grade (67.4 and 78.5%, respectively), and agreement with the final diagnosis was high (>90%). Variations in angle grading other than naming structures were observed (2.0, 30, and 3.9% for optometrist, general ophthalmologist, and glaucoma specialist, respectively). Most of the time, trabecular pigmentation or iris configuration was not described.

CONCLUSIONS

Fair to moderate concordance in gonioscopy was achieved between optometrists and ophthalmologists in a collaborative care clinic in which there is consistent feedback and clinical review. To move toward unified medical records and a telemedicine model, improved consistency of record keeping and angle description is required.

Redundancy of Progress Notes for Serial Office Visits

Using sequence alignment to compare more than 12,000 pairs of progress notes, we find that progress notes were, on average, 74.5% redundant with the prior progress note written for the same patient.

Surgical Outcomes and Quality Assessment of Trabeculectomy: Leveraging Electronic Health Records for Clinical Data Visualization

PRéCIS:: This electronic medical record-based study demonstrates 1 approach to monitor clinical outcomes for individual physicians performing trabeculectomy.

PURPOSE

The purpose of this study was to develop an interactive data visualization platform for evaluating trabeculectomy outcomes and monitoring clinical care quality.

PATIENTS AND METHODS

This is a retrospective electronic health record study in a glaucoma division of an academic medical center. We included 633 patients who underwent trabeculectomy between July 2016 and December 2018. Data were collected for intraocular pressure (IOP), vision loss, number of follow-up visits, and return to the operating room within the initial 3 months. Regression analyses were used to assess factors associated with these study outcomes. Risk of IOP ≤5 mm Hg was assessed using survival analysis. An interactive data visualization platform was created.

RESULTS

A total of 429 trabeculectomy and 204 combined surgeries were analyzed, with preoperative IOP of 21.9±9.4 and 19.4±6.9 mm Hg, respectively. Mean pressure declined by 53% and 41% (P=0.001) by 3 months. Risk of pressure ≤5 mm Hg was higher in white patients and those who underwent trabeculectomy alone. At 3 months, patients on average had 5 clinic visits; 5.5% required additional surgical procedures, and 18% experienced loss of at least 3 lines of best-recorded (not best-corrected) vision. Returning to the operating room was significantly associated with an increased number of clinic visits (coefficient=3.94) and higher odds of vision loss (odds ratio=11.12).

CONCLUSIONS

Over the initial 3 months after trabeculectomy, additional surgeries are rare, while a significant proportion of patients lost vision, and this was strongly associated with a need to return to the operating room. Interactive electronic health record data visualization can be a useful tool for monitoring clinical outcomes.

Changes in Electronic Health Record Use Time and Documentation over the Course of a Decade

PURPOSE

With the current wide adoption of electronic health records (EHRs) by ophthalmologists, there are widespread concerns about the amount of time spent using the EHR. The goal of this study was to examine how the amount of time spent using EHRs as well as related documentation behaviors changed 1 decade after EHR adoption.

DESIGN

Single-center cohort study.

PARTICIPANTS

Six hundred eighty-five thousand three hundred sixty-one office visits with 70 ophthalmology providers.

METHODS

We calculated time spent using the EHR associated with each individual office visit using EHR audit logs and determined chart closure times and progress note length from secondary EHR data. We tracked and modeled how these metrics changed from 2006 to 2016 with linear mixed models.

MAIN OUTCOME MEASURES

Minutes spent using the EHR associated with an office visit, chart closure time in hours from the office visit check-in time, and progress note length in characters.

RESULTS

Median EHR time per office visit in 2006 was 4.2 minutes (interquartile range [IQR], 3.5 minutes), and increased to 6.4 minutes (IQR, 4.5 minutes) in 2016. Median chart closure time was 2.8 hours (IQR, 21.3 hours) in 2006 and decreased to 2.3 hours (IQR, 18.5 hours) in 2016. In 2006, median note length was 1530 characters (IQR, 1435 characters) and increased to 3838 characters (IQR, 2668.3 characters) in 2016. Linear mixed models found EHR time per office visit was 31.9±0.2% (P < 0.001) greater from 2014 through 2016 than from 2006 through 2010, chart closure time was 6.7±0.3 hours (P < 0.001) shorter from 2014 through 2016 versus 2006 through 2010, and note length was 1807.4±6.5 characters (P < 0.001) longer from 2014 through 2016 versus 2006 through 2010.

CONCLUSIONS

After 1 decade of use, providers spend more time using the EHR for an office visit, generate longer notes, and close the chart faster. These changes are likely to represent increased time and documentation pressure for providers. Electronic health record redesign and new documentation regulations may help to address these issues.

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

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

Changing trends in postoperative cataract care: impact of electronic patient records in optometrist-delivered shared care

BACKGROUND

This study evaluates a community optometrist-delivered postoperative care scheme in patients discharged from the hospital ophthalmology department following uncomplicated cataract surgery.

AIM

The aim of this study is to assess the efficacy of electronic patient records (EPR) in facilitating co-managed cataract care.

METHODS

We performed a retrospective analysis of a prospectively maintained Medisoft EPR database of postoperative cataract review data at a single centre, Sligo University Hospital (SUH), which serves a large and predominantly rural catchment area. All patients undergoing cataract surgery at SUH from October 2012 to September 2013 were included in this study. A total of 39 optometric practices, all with access to the Medisoft EPR software, participated in this pilot co-management scheme.

RESULTS

One thousand four hundred and twenty-two cataract surgeries were performed in SUH (55% female, 45% male); 1011 patients (71%) were discharged to the community on the day of cataract surgery. Complete postoperative feedback (i.e. data on refraction, visual acuity and intraocular pressure) was available in 97% of these patients compared to 50% of patients reviewed in the hospital. Patients followed up by optometrists were twice as likely to have complete postoperative clinical details (RR = 1.934, 95% CI: 1.759-2.126, p < 0.0001). Overall, 65% of operations were performed on first eyes. Hospital doctors were more likely to document requirement for second eye surgery compared to community optometrists (RR = 1.434, 95% CI: 1.302-1.580, p < 0.0001).

CONCLUSIONS

Optometrists provided an excellent postoperative care service with superior postoperative feedback rates compared to hospital doctors. EPRs facilitate a postoperative shared-care pathway that is of high quality and efficiency with major economic advantages.

Barriers to electronic medical record implementation: a comparison between ophthalmology and other surgical specialties in Canada

OBJECTIVE

In the present study, the barriers limiting widespread adoption of electronic medical records (EMRs) among Canadian ophthalmologists were evaluated in comparison with physicians from other surgical specialities. The published literature regarding EMR use in ophthalmic practice was also reviewed.

DESIGN

Population-based, cross-sectional study.

PARTICIPANTS

A total of 1199 Canadian surgeons participating in the 2014 National Physician Survey (NPS).

METHODS

Data regarding speciality surgeons' adoption of EMR programs were extracted from the 2014 NPS, a nationwide survey of practicing physicians in Canada. The data were entered into a spreadsheet, and basic statistical analyses, including χ² analyses, were performed to compare the responses of ophthalmologists to other surgeons.

RESULTS

Compared with other surgeons, ophthalmologists surveyed were significantly more likely to identify the following barriers to EMR adoption: "no suitable product for my practice" (p = 0.01), "too costly" (p = 0.0006), "too time consuming" (p < 0.0001), and "planning to retire soon" (p = 0.001). No statistically detectable differences were found between ophthalmologists and other surgeons for the following barriers: privacy concerns, reliability concerns, and lack of training.

CONCLUSIONS

The barriers that limit increased EMR adoption among Canadian ophthalmologists are different from those of other surgeons. This may be attributed to unique features of the field, including heavy reliance on hand-drawn figures in documentation, high patient volume, and the high costs associated with independent practice. Given the well-established benefits of EMR technology, consideration should be given to implementing strategies to mitigate these barriers. Additional research may help determine which specific improvements can be made to increase the use of EMR systems by ophthalmologists.

Prototype Development: Context-Driven Dynamic XML Ophthalmologic Data Capture Application

Background

The capture and integration of structured ophthalmologic data into electronic health records (EHRs) has historically been a challenge. However, the importance of this activity for patient care and research is critical.

Objective

The purpose of this study was to develop a prototype of a context-driven dynamic extensible markup language (XML) ophthalmologic data capture application for research and clinical care that could be easily integrated into an EHR system.

Methods

Stakeholders in the medical, research, and informatics fields were interviewed and surveyed to determine data and system requirements for ophthalmologic data capture. On the basis of these requirements, an ophthalmology data capture application was developed to collect and store discrete data elements with important graphical information.

Results

The context-driven data entry application supports several features, including ink-over drawing capability for documenting eye abnormalities, context-based Web controls that guide data entry based on preestablished dependencies, and an adaptable database or XML schema that stores Web form specifications and allows for immediate changes in form layout or content. The application utilizes Web services to enable data integration with a variety of EHRs for retrieval and storage of patient data.

Conclusions

This paper describes the development process used to create a context-driven dynamic XML data capture application for optometry and ophthalmology. The list of ophthalmologic data elements identified as important for care and research can be used as a baseline list for future ophthalmologic data collection activities.

Evaluating a Web-Based Coaching Program Using Electronic Health Records for Patients With Chronic Obstructive Pulmonary Disease in China: Randomized Controlled Trial

Background

Chronic obstructive pulmonary disease (COPD) is now the fourth leading cause of death in the world, and it continues to increase in developing countries. The World Health Organization expects COPD to be the third most common cause of death in the world by 2020. Effective and continuous postdischarge care can help patients to maintain good health. The use of electronic health records (EHRs) as an element of community health care is new technology in China.

Objective

The aim of this study was to develop and evaluate a Web-based coaching program using EHRs for physical function and health-related quality of life for patients with COPD in China.

Methods

A randomized controlled trial was conducted from 2008 to 2015 at two hospitals. The control group received routine care and the intervention group received routine care with the addition of the Web-based coaching program using EHRs. These were used to manage patients’ demographic and clinical variables, publish relevant information, and have communication between patients and health care providers. Participants were not blinded to group assignment. The effects of the intervention were evaluated by lung function, including percent of forced expiratory volume in 1 second (FEV1%), percent of forced vital capacity (FVC%), peak expiratory flow (PEF), maximum midexpiratory flow; St George’s Respiratory Questionnaire (SGRQ); Modified Medical Research Council Dyspnea Scale (MMRC); and 6-Minute Walk Test (6MWT). Data were collected before the program, and at 1, 3, 6, and 12 months after the program.

Results

Of the 130 participants, 120 (92.3%) completed the 12-month follow-up program. There were statistically significant differences in lung function (FEV1%: F1,4=5.47, P=.002; FVC%: F1,4=3.06, P=.02; PEF: F1,4=12.49, P<.001), the total score of SGRQ (F1,4=23.30, P<.001), symptoms of SGRQ (F1,4=12.38, P<.001), the activity of SGRQ (F1,4=8.35, P<.001), the impact of SGRQ (F1,4=12.26, P<.001), MMRC (F1,4=47.94, P<.001), and 6MWT (F1,4=35.54, P<.001) between the two groups with the variation of time tendency.

Conclusions

The Web-based coaching program using EHRs in China appears to be useful for patients with COPD when they are discharged from hospital into the community. It promotes the sharing of patients’ medical information by hospital and community nurses, and achieves dynamic management and follow-up analysis for patients’ disease. In addition, this program can postpone the decreasing rate of lung function, improve quality of life, decrease dyspnea, and increase physical capacity.

Distribution and extent of electronic medical record utilisation in eye units across the United Kingdom: a cross-sectional study of the current landscape

OBJECTIVES

Ophthalmology units across the UK vary widely in their adoption of electronic medical records (EMR). There is a lack of evidence to show the extent and progress of EMR adoption. The aim of this study was to capture a snapshot of the current landscape of EMR use, as a baseline for comparison in future studies.

SETTING

An electronic survey questionnaire was sent to all NHS ophthalmology Units in the UK.

PARTICIPANTS

A total of 104 National Health Service (NHS) ophthalmology units participated in the survey, which was carried out over 6 months from December 2013 to June 2014.

PRIMARY AND SECONDARY OUTCOME MEASURES

Respondents were asked about technology usage pertaining to specific processes in the clinic workflow. This allowed us to determine the extent of EMR usage and details about current use or planned implementation by each unit.

RESULTS

77.6% (n=104) of NHS ophthalmology units responded. 45.3% (n=48) of units were currently using an EMR and a further 26.4% (n=28) of units plan to implement EMR within 2 years. 70.8% of units with a current EMR system use Medisoft. EMR is used by all clinicians in 37.5% and by all subspecialties offered at the unit in 27.0%. In 56.3%, new clinical notes are entered into EMR only by clinicians. All imaging devices are networked to EMR in 28.3%. In 46.7%, EMR is accessible by other specialties within the same hospital. 71.1% would recommend EMR to a colleague.

CONCLUSIONS

EMR has the potential to address current limitations of patient information transfer and sharing in ophthalmology. It is pleasing to see a significant proportion of units already engaging with EMR or having plans to do so in the near future. However, differing EMR systems and lack of remote access mean further optimisation of these record systems are needed to allow data transfer between units.

[Development of an ophthalmological clinical information system for inpatient eye clinics]

BACKGROUND

In times of increased digitalization in healthcare, departments of ophthalmology are faced with the challenge of introducing electronic clinical health records (EHR); however, specialized software for ophthalmology is not available with most major EHR sytems. The aim of this project was to create specific ophthalmological user interfaces for large inpatient eye care providers within a hospitalwide EHR. Additionally the integration of ophthalmic imaging systems, scheduling and surgical documentation should be achieved.

MATERIAL AND METHODS

The existing EHR i.s.h.med (Siemens, Germany) was modified using advanced business application programming (ABAP) language to create specific ophthalmological user interfaces for reproduction and moreover optimization of the clinical workflow.

RESULTS

A user interface for documentation of ambulatory patients with eight tabs was designed. From June 2013 to October 2014 a total of 61,551 patient contact details were documented. For surgical documentation a separate user interface was set up. Digital clinical orders for documentation of registration and scheduling of operations user interfaces were also set up. A direct integration of ophthalmic imaging modalities could be established.

CONCLUSION

An ophthalmologist-orientated EHR for outpatient and surgical documentation for inpatient clinics was created and successfully implemented. By incorporation of imaging procedures the foundation of future smart/big data analyses was created.

A Two-Year Longitudinal Assessment of Ophthalmologists' Perceptions after Implementing an Electronic Health Record System

OBJECTIVES

To understand the attitudes and perceptions of ophthalmologists toward an electronic health record (EHR) system, before and after its clinical implementation.

METHODS

Ophthalmologists at a single large academic ophthalmology department were surveyed longitudinally before and after implementation of a new EHR system. The survey measured ophthalmologists' attitudes toward implementation of a new EHR. Questions focused on satisfaction, efficiency, and documentation. All attending physicians (between 56 and 61 at various time points) in the University of Michigan Department of Ophthalmology and Visual Sciences were surveyed. We plotted positive responses to survey questions and assessed whether perceptions followed a J-curve with an initial decrease followed by an increase surpassing pre-implementation levels.

RESULTS

Survey responses were received from 32 (52%) ophthalmologists pre-implementation, and 28 (46%) at 3 months, 35 (57%) at 7 months, 40 (71%) at 13 months and 39 (67%) at 24 months post-implementation. After EHR implementation respondents were more likely to express concerns about their ability to create high-quality documentation (p<0.01) and the impact of an electronic health record on meaningful patient interaction (p<0.01). Physicians did not report a significant change in the amount of time spent documenting outside of regular clinical work hours (p=0.54) or on their clinic efficiency and workflow (p=0.97). There was no significant change in overall job satisfaction during the study period (p=0.69). We did not observe a J-curve for any of the survey responses analyzed.

CONCLUSIONS

As ophthalmology practices continue to transition to EHRs, adapting them to their specific culture and needs is important to maintain efficiency and user satisfaction. This study identifies areas of concern to ophthalmologists that may be addressed through education of physicians and customization of software as other practices move forward with EHR implementation.

Pneumatic Retinopexy for Rhegmatogenous Retinal Detachment in Pseudophakia

PURPOSE

To identify the characteristics predictive of unfavorable outcomes for pneumatic retinopexy (PR) in the repair of pseudophakic rhegmatogenous retinal detachments (RD).

METHODS

A retrospective chart review was performed at a single institution to identify patients who underwent PR in pseudophakic eyes. Pre- and postoperative data were reviewed and analyzed to evaluate predictive factors of failure.

RESULTS

Forty-four patients met the study criteria. PR was successful in 23 (52.3%) patients. The failed cases underwent scleral buckles, vitrectomies, or both. A retinal tear located outside the superior four clock hours was a significant predictor of PR failure. At six months post-intervention, the failure and success groups were statistically similar for vision and rate of reattachment.

CONCLUSIONS

Modified criteria for PR in pseudophakia may include cases with retinal breaks within the superior four clock hours. If further surgery is required, the final vision and anatomic reattachment are not disadvantaged by the initial PR procedure.

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

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.

Vision and eye health in children 36 to <72 months: proposed data system

Supplemental digital content is available in the text.

Purpose

This article provides a rationale for developing an integrated data system for recording vision screening and eye care follow-up outcomes in preschool-aged children. The recommendations were developed by the National Expert Panel to the National Center for Children’s Vision and Eye Health at Prevent Blindness and funded by the Maternal and Child Health Bureau of the Health Resources and Services Administration, US Department of Health and Human Services. Guidance is provided regarding specific elements to be included, as well as the characteristics and architecture of such a data system. Vision screening for preschool-aged children is endorsed by many organizations concerned with children’s health issues. Currently, there is a lack of data on the proportion of children screened and no effective system to ensure that children who fail screenings access appropriate comprehensive eye examinations and follow-up care.

Results

The expansion of currently existing, or developing integrated health information systems, which would include child-level vision screening data, as well as referral records and follow-up diagnosis and treatment, is consistent with the proposed national approach to an integrated health information system (National Health Information Infrastructure). Development of an integrated vision data system will enhance eye health for young children at three different levels: (1) the child level, (2) the health care provider level, and (3) an epidemiological level.

Conclusions

It is critical that the end users, the professionals who screen children and the professionals who provide eye care, be involved in the development and implementation of the proposed integrated data systems. As essential stakeholders invested in ensuring quality eye care for children, this community of professionals should find increasing need and opportunities at local, state, and national levels to contribute to cooperative guidance for data system development.

The long-term financial and clinical impact of an electronic health record on an academic ophthalmology practice

Purpose. To examine financial and clinical work productivity outcomes associated with the use of the electronic health record (EHR). Methods. 191,360 billable clinical encounters were analyzed for 12 clinical providers over a 9-year study period during which an EHR was implemented. Main outcome measures were clinical revenues collected per provider and secondary outcomes were charge capture, patient visit coding levels, transcription costs, patient visit volume per provider, digital drawing, and digital imaging volume. Results. The difference in inflation adjusted net clinical revenue per provider per year did not change significantly in the period after EHR implementation (mean = $404,198; SD = $17,912) than before (mean = $411,420; SD = $39,366) (P = 0.746). Charge capture, the proportion of higher- and lower-level visit codes for new and established patients, and patient visits per provider remained stable. A total savings of $188,951 in transcription costs occurred over a 4-year time period post-EHR implementation. The rate of drawing the ophthalmic exam in the EHR was low (mean = 2.28%; SD = 0.05%) for all providers. Conclusions. This study did not show a clear financial gain after EHR implementation in an academic ophthalmology practice. Ophthalmologists do not rely on drawings to document the ophthalmic exam; instead, the ophthalmic exam becomes text-driven in a paperless world.

Electronic health record impact on productivity and efficiency in an academic pediatric ophthalmology practice

PURPOSE

To measure the effect of electronic health record (EHR) implementation on productivity and efficiency in the pediatric ophthalmology division at an academic medical center.

METHODS

Four established providers were selected from the pediatric ophthalmology division at the Oregon Health & Science University Casey Eye Institute. Clinical volume was compared before and after EHR implementation for each provider. Time elapsed from chart open to completion (OTC time) and the proportion of charts completed during business hours were monitored for 3 years following implementation.

RESULTS

Overall there was an 11% decrease in clinical volume following EHR implementation, which was not statistically significant (P = 0.18). The mean OTC time ranged from 5.5 to 28.3 hours among providers in this study, and trends over time were variable among the four providers. Forty-four percent of all charts were closed outside normal business hours (30% on weekdays, 14% on weekends).

CONCLUSIONS

EHR implementation was associated with a negative impact on productivity and efficiency in our pediatric ophthalmology division.

A comparison of paper documentation to electronic documentation for trauma resuscitations at a level I pediatric trauma center

INTRODUCTION

Although the electronic medical record reduces errors and improves patient safety, most emergency departments continue to use paper documentation for trauma resuscitations. The purpose of this study was to compare the completeness of paper documentation with that of electronic documentation for trauma resuscitations.

METHODS

The setting was a level I pediatric trauma center where 100% electronic documentation was achieved in August 2012. A random sample of trauma resuscitations documented by paper (n=200) was compared with a random sample of trauma resuscitations documented electronically (n=200) to identify the presence or absence of the documentation of 11 key data elements for each trauma resuscitation.

RESULTS

The electronic documentation more frequently captured 5 data elements: time of team activation (100% vs 85%, P<.00), primary assessment (94% vs 88%, P<.036), arrival time of attending physician (98% vs 93.5%, P<.026), intravenous fluid volume in the emergency department (94% vs 88%, P<.036), and disposition (100% vs 89.5%, P<.00). The paper documentation more often recorded one data element: volume of intravenous fluids administered prior to arrival (92.5% vs 100%, P<.00). No statistical difference in documentation rates was found for 5 data elements: vital signs, treatment by emergency medical personnel, arrival time in the emergency department, and level of trauma alert activation.

DISCUSSION

Electronic documentation produced superior records of pediatric trauma resuscitations compared with paper documentation. Because the electronic medical record improves patient safety, it should be adopted as the standard documentation method for all trauma resuscitations.