Integrating direct electronic collection of data from patients into the process of care for eye care professionals

Abstract

Enabling collection of clinical data directly from patients has the potential to increase data accuracy and augment patient engagement in the care process. Most patient data entry systems have been created independent of electronic health records, and few studies have explored how patient entered data can be integrated in the documentation of a clinical encounter. In this paper we describe a formative evaluation study using three different methodologies through which we identified requirements for direct data entry by patients and the subsequent incorporation of these data into the documentation process. The greatest challenges included ensuring confidentiality of records between patients, capturing medication histories from patients, displaying and distinguishing new and previously entered data for provider review, and supporting patient educational needs. The resulting computer tablet-based data collection tool has been deployed to 30 primary care optometry practices where it is successfully used to document care for patients with glaucoma.

Figure 1.

Screen Shots from the Patient Data Entry Module (A & B) and the Provider Data Entry Module (C). See Text for Details.

Figure 2.

Workflow for Computer Tablet Use. Aqua boxes = staff tasks, green boxes = patient tasks, yellow boxes = provider tasks.