Accuracy and speed of electronic health record versus paper-based ophthalmic documentation strategies

Abstract

Purpose: To compare accuracy and speed of keyboard and mouse electronic health record (EHR) documentation strategies with those of a paper documentation strategy.

Design: Prospective cohort study.

Methods: Three documentation strategies were developed: (1) keyboard EHR, (2) mouse EHR, and (3) paper. Ophthalmology trainees recruited for the study were presented with 5 clinical cases and documented findings using each strategy. For each case-strategy pair, findings and documentation time were recorded. Accuracy of each strategy was calculated based on sensitivity (fraction of findings in actual case that were documented by subject) and positive ratio (fraction of findings identified by subject that were present in the actual case).

Results: Twenty subjects were enrolled. A total of 258 findings were identified in the 5 cases, resulting in 300 case-strategy pairs and 77 400 possible total findings documented. Sensitivity was 89.1% for the keyboard EHR, 87.2% for mouse EHR, and 88.6% for the paper strategy (no statistically significant differences). The positive ratio was 99.4% for the keyboard EHR, 98.9% for mouse EHR, and 99.9% for the paper strategy (P < .001 for mouse EHR vs paper; no significant differences between other pairs). Mean ± standard deviation documentation speed was significantly slower for the keyboard (2.4 ± 1.1 seconds/finding) and mouse (2.2 ± 0.7 seconds/finding) EHR compared with the paper strategy (2.0 ± 0.8 seconds/finding). Documentation speed of the mouse EHR strategy worsened with repetition.

Conclusions: No documentation strategy was perfectly accurate in this study. Documentation speed for both EHR strategies was slower than with paper. Further studies involving total physician time requirements for ophthalmic EHRs are required.

FIGURE 1.

Representative interface for keyboard electronic health record (EHR) documentation strategy of the ophthalmic examination developed by authors for this study. Textboxes are used for keyboard input of ophthalmic examination findings. Tab key or mouse is used to advance to the next box. OD = right eye; OS = left eye; SLE = slit lamp examination.

FIGURE 2.

Representative interface of a mouse electronic health record (EHR) documentation strategy of the ophthalmic examination developed by authors for this study. Checkboxes (e.g., presence of guttae) and pull-down menus (e.g., severity from 1+ to 4+) with common ophthalmic examination findings are used for selection. Comment box is used for free text entry of additional findings. Scrollbar (right side) is used to advance the interface. OD = right eye; OS = left eye.

FIGURE 3.

Paper-based strategy for documentation of the ophthalmic examination used for this study. Preprinted templates allow for spatial arrangement of ophthalmic examination findings to be hand written or hand drawn. A/C = anterior chamber; ACIOL = AC intraocular lens; Conj = conjunctiva; Ext = external structures; OD = right eye; OS = left eye; PCIOL = posterior chamber intraocular lens.

FIGURE 4.

Graphs showing the learning effects of (Top) keyboard electronic health record (EHR), (Middle) mouse EHR, and (Bottom) paper-based strategies for ophthalmic examination documentation. There were no statistically significant learning effects with keyboard EHR (Top, P = .58) or paper (Bottom, P = .14). There was a statistically significant worsening in documentation time as more cases were documented using the mouse EHR strategy (Middle, P < .02).