Electronic health records in ophthalmology: source and method of documentation.

Abstract

Purpose : The electronic health record (EHR) has challenged clinical efficiency, prompting changes to traditional documentation including the use of copy and paste and templates (“import technology”), as well as increasing authorship by clinical support staff (e.g. technicians, photographers). We performed a retrospective observational chart review to quantitatively assess the role of import technology and support staff authorship in progress notes for new and return patients in ophthalmology clinics.

Methods : We analyzed notes from 8 providers (representing 4 subspecialties) over a 6-month time period. All progress notes from this interval were filtered for top 5 ICD-10 diagnosis codes for the given provider, and individual notes were selected at random. A manual review of each note was then performed to determine attribution source: manually-entered vs. imported, authorship (provider, support staff/technician, photographer) and timing of documentation (during/after office visit). Notes from visits involving trainees as well as notes missing time stamp data were excluded. We present a preliminary data set including 1 new and 1 return patient note from each provider. The Oregon Health and Science University Institutional Review Board approved this chart review study.

Results : Imported text entry was responsible for the majority of text in new and return patients (74% and 85%, respectively; Table 1). Support staff members authored significant portions of notes (40% new, 52% return; Table 2). Finally, a similar percentage of documentation is completed following office visits with new patients compared to return patients (18% and 6% respectively, p= 0.18).

Conclusions : Our findings suggest that the current EHR documentation system relies heavily on imported text and support staff authorship. These strategies pose questions regarding accuracy, efficiency, and overall effectiveness of progress notes within the EHR.

This is an abstract that was submitted for the 2018 ARVO Annual Meeting, held in Honolulu, Hawaii, April 29 - May 3, 2018.

 

Table 1. Imported text comprises the majority of new and return patient notes (74% and 85%, respectively). Of imported text, templates contribute the most text in new and return patient notes (73% and 68%).

 

Table 2. Technicians and photographers are responsible for a significant percentage of text entry in new and return patient notes (40% and 52%, respectively).