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David Sanders, Daniel Lattin, Daniel Tu, Sarah Read-Brown, David Wilson, Thomas Hwang, John Morrison, Thomas Yackel, Michael Chiang; Electronic health record (EHR) systems in ophthalmology: Impact on clinical documentation. Invest. Ophthalmol. Vis. Sci. 2013;54(15):4424.
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To evaluate quantitative and qualitative differences in ophthalmology documentation between paper and electronic health record (EHR) systems.
An academic ophthalmology department implemented an EHR (EpiCare; Epic, Madison, WI) in 2006. Database queries were performed to identify cases in which the same provider documented the same problems on different dates, using paper vs. EHR methods. A total of 150 consecutive pairs of matched paper and EHR notes were documented by 3 attending ophthalmologist providers. 50 consecutive pairs of exams were examined in 3 different diseases: age-related macular degeneration (AMD), glaucoma, and pigmented choroidal lesions (PCL). Quantitative measures were used to compare completeness of documenting the complete ophthalmological exam, as well as disease-specific critical findings using paper vs. EHR. “Documentation score,” was defined as the number of exam elements recorded for the slit lamp exam, fundus exam, complete ophthalmological exam, and critical clinical findings for each disease. Qualitative differences in paper vs. EHR documentation were illustrated by selecting representative paired examples.
For all 3 diseases (AMD, glaucoma, PCL), the number of complete examination findings recorded was significantly lower with paper as opposed to EHR (p≤0.004). Among the 3 individual examination sections (general, slit lamp, fundus) for the 3 diseases, 7 of the 9 possible combinations had lower mean documentation scores with paper than EHR notes. For 2 of the 3 diseases, the number of critical clinical findings recorded was significantly lower using paper than EHR notes (p≤0.022). All (150/150) paper notes relied on graphical representations using annotated hand-drawn sketches, whereas no (0/150) EHR notes contained drawings. Instead, EHRs documented clinical findings using textual descriptions and interpretations.
There are fundamental quantitative and qualitative differences in the nature of paper vs. EHR documentation of ophthalmic findings. Additional studies examining the impact of EHRs on improving efficiency, safety, and quality of ophthalmic care will be required.
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