eHealth 2015 Special Issue: Impact of Electronic Health Records on the Completeness of Clinical Documentation Generated during Diabetic Retinopathy Consultations.

Academic Article

Abstract

  • BACKGROUND: Two years ago, the Diabetic Retinopathy (DRP) and Traumatology clinic of the Department of Ophthalmology and Optometrics at the Medical University of Vienna, Austria switched from paper-based to electronic health records. A customized electronic health record system (EHR-S) was implemented. OBJECTIVES: To assess the completeness of information documented electronically compared with manually during patient visits. METHODS: The Preferred Practice Pattern for Diabetic Retinopathy published by the American Academy of Ophthalmology was distilled into a list of medical features grouped into categories to be assessed and documented during the management of patients with DRP. The last seventy paper-based records and all electronic records generated since the switch were analyzed and graded for the presence of features on the list and the resulting scores compared. RESULTS: In all categories, clinical documentation was more complete in the EHR group. CONCLUSIONS: In our setting, the implementation of an EHR-S showed a statistically significant positive impact on documentation completeness.
  • Published In

    Keywords

  • Care records, Electronic health records and systems, Encounter notes, Ophthalmology, Testing and evaluation, Diabetic Retinopathy, Documentation, Electronic Health Records, Humans, Quality Control, Referral and Consultation, Telemedicine
  • Digital Object Identifier (doi)

    Author List

  • Mitsch C; Huber P; Kriechbaum K; Scholda C; Duftschmid G; Wrba T; Schmidt-Erfurth U
  • Start Page

  • 478
  • End Page

  • 487
  • Volume

  • 6
  • Issue

  • 3