Purpose:
The purpose of this project was to create a universally accessible electronic medical record tailored for an ophthalmology practice that would be fully functional to include ophthalmic drawings, imaging from FA, OCT, Photos, Visual Fields. Additionally, the system would be low in cost, secure, and be engineered from readily available commercial software products. The system would be designed and created by an ophthalmology resident physician.
Methods:
The method of development of this project was over 8weeks using Microsoft Infopath and Office Software, a Toshiba Portege Tablet Laptop PC and Microsoft Server Software
Results:
A simple yet highly effective electronic medical record was created that includes a touchscreen, incorporation of on screen fundus and anterior segment drawings, incorporation of visual fields, OCT, FA, photos. The files are saved utilizing an electronic signature that prevents tampering or alteration. Additionally, diagnosis and treatment along with patient characteristics and examination data are automatically collated to a database. The system utilizes software that is compatible with Microsoft Office which is universally available for most clinicians. Other physicians who do not utilize this database system are able to access these files through Microsoft Word. Finally, utilizing a server software, multiple computers are able to access this system to input and extract data wirelessly. The costs for this project were under $3000.
Conclusions:
Electronic Medical Records are accessories to health care delivery that reduce costs, medical errors, time, and unnecessary repeat testing. The U.S Government has mandated that electronic medical records be included in health care delivery within the near future. This project shows that a highly effective electronic medical record can be designed for ophthalmology by a clinician with limited computer knowledge over a short period of time that can be secure,effective and user friendly.
Keywords: clinical (human) or epidemiologic studies: health care delivery/economics/manpower • imaging/image analysis: clinical • image processing