Electronic health record systems in ophthalmology: impact on clinical documentation

Abstract

Objective: To evaluate quantitative and qualitative differences in documentation of the ophthalmic examination between paper and electronic health record (EHR) systems.

Design: Comparative case series.

Participants: One hundred fifty consecutive pairs of matched paper and EHR notes, documented by 3 attending ophthalmologist providers.

Methods: An academic ophthalmology department implemented an EHR system in 2006. Database queries were performed to identify cases in which the same problems were documented by the same provider on different dates, using paper versus EHR methods. This was done for 50 consecutive pairs of examinations in 3 different diseases: age-related macular degeneration (AMD), glaucoma, and pigmented choroidal lesions (PCLs). Quantitative measures were used to compare completeness of documenting the complete ophthalmologic examination, as well as disease-specific critical findings using paper versus an EHR system. Qualitative differences in paper versus EHR documentation were illustrated by selecting representative paired examples.

Main outcome measures: (1) Documentation score, defined as the number of examination elements recorded for the slit-lamp examination, fundus examination, and complete ophthalmologic examination and for critical clinical findings for each disease. (2) Paired comparison of qualitative differences in paper versus EHR documentation.

Results: For all 3 diseases (AMD, glaucoma, PCL), the number of complete examination findings recorded was significantly lower with paper than the EHR system (P ≤ 0.004). Among the 3 individual examination sections (general, slit lamp, fundus) for the 3 diseases, 5 of the 9 possible combinations had significantly 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 versus 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, the EHR systems documented clinical findings using textual descriptions and interpretations.

Conclusions: There were quantitative and qualitative differences in the nature of paper versus EHR documentation of ophthalmic findings in this study. The EHR notes included more complete documentation of examination elements using structured textual descriptions and interpretations, whereas paper notes used graphical representations of findings.

Financial disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Figure 1.

Example of clinical documentation of macular degeneration on paper versus electronic health record (EHR) systems. The patient was examined by the same provider on different dates using the 2 systems. A, Paper documentation showing the use of structured checkboxes and annotated drawings. B, Electronic health record system documentation emphasizing structured textual descriptions and interpretations. C, Photographic documentation of clinical findings. For portions of the note shown, paper documentation scores for the slit-lamp examination, fundus examination, and critical clinical findings would be calculated as 6/6, 3/5, and 2/4, respectively. The EHR documentation scores for the slit-lamp examination, fundus examination, and critical clinical findings would be calculated as 6/6, 5/5, and 1/4, respectively. clr = clear; Conj = conjunctiva; D = optic disc; DQ = deep, quiet; IRH = intraretinal hemorrhage; M = macula; MGD = meibomian gland dysfunction; nl = normal; NS = nuclear sclerosis; NVI = neovascularization of the iris; NS = nuclear sclerosis; OS = left eye; P = peripheral retina; PCIOL = posterior chamber intraocular lens; PVD = posterior vitreous detachment; SRF = subretinal fluid; V = vitreous; WQ = white, quiet.

Figure 2.

Example of clinical documentation of primary open-angle glaucoma on paper versus electronic health record (EHR) systems. Patient was examined by the same faculty provider on different dates using the 2 systems. A, Paper documentation emphasizing written descriptions and drawings. B, Electronic health record system documentation emphasizing structured textual descriptions and interpretations of optic nerve findings. C, Photographic documentation of clinical findings. For portions of the note shown, paper documentation scores for the slit-lamp examination, fundus examination, and critical clinical findings would be calculated as 10/12, 8/10, and 2/2, respectively. The EHR documentation scores for the slit-lamp examination, fundus examination, and critical clinical findings would be calculated as 12/12, 2/10, and 2/2, respectively. AC = anterior chamber; C/D = cup-to-disc ratio; NFL = nerve fiber layer; OD = right eye; OS = left eye; OU = both eyes; SLE = slit-lamp examination.

Figure 3.

Example of clinical documentation of pigmented choroidal lesion (PCL) on paper versus electronic health record (EHR) systems. Patient with PCL and diabetic retinopathy in the left eye was examined by the same faculty provider on different dates using the 2 systems. A, Paper documentation with handwritten examination findings and annotated drawings of fundus examination (e.g. X to represent panretinal photocoagulation scars). B, Electronic health record system documentation emphasizing structured textual descriptions and interpretations (e.g., comparison with previous examinations and good PRP peripherally summary). C, Photographic documentation of clinical findings. For portions of the note shown, paper documentation scores for the slit-lamp examination, fundus examination, and critical clinical findings would be calculated as 5/6, 1/5, and 3/4, respectively. The EHR documentation scores for the slit-lamp examination, fundus examination, and critical clinical findings would be calculated as 6/6, 5/5, and 2/4, respectively. AC = anterior chamber; CDR = cup-to-disc ratio; CSME = clinically significant macular edema; d/c = deep/clear; DD = disc diameters; LE = left eye; nl = normal; OS = left eye; PCIOL = posterior chamber intraocular lens; PRP = panretinal photocoagulation; SPK = superficial punctate keratitis; SRF = subretinal fluid.

Figure 7.

Examples of clinical documentation challenges using electronic health record systems, in which ophthalmic and systemic issues are combined. A, Problem list. B, Medication list.