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

Journal: Applied Clinical Informatics
ISSN: 1869-0327
DOI: https://doi.org/10.4338/ACI-2015-03-RA-0028
Issue: Vol. 6: Issue 3 2015
Pages: 478-487

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

Research Article

Special Topic: eHealth2015

C. Mitsch (1), P. Huber (1), K. Kriechbaum (1), C. Scholda (1), G. Duftschmid (2), T. Wrba (2), U. Schmidt-Erfurth (1)

(1) Medical University of Vienna, Department of Ophthalmology and Optometrics, Vienna, Austria; (2) Medical University of Vienna, Center for Medical Statistics, Informatics, and Intelligent Systems, Vienna, Austria

Keywords

Testing and evaluation, Electronic health records and systems, ophthalmology, Encounter notes, Care records

Summary

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.

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