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Electronic Health Records in Ophthalmology: Source and Method of Documentation.

Authors:
Bradley S Henriksen Isaac H Goldstein Adam Rule Abigail E Huang Haley Dusek Austin Igelman Michael F Chiang Michelle R Hribar

Am J Ophthalmol 2020 03 5;211:191-199. Epub 2019 Dec 5.

Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, Oregon, USA; Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, USA. Electronic address:

Purpose: This study analyzed and quantified the sources of electronic health record (EHR) text documentation in ophthalmology progress notes.

Design: EHR documentation review and analysis.

Methods: Setting: a single academic ophthalmology department.

Study Population: a cohort study conducted between November 1, 2016, and December 31, 2018, using secondary EHR data and a follow-up manual review of a random samples. The cohort study included 123,274 progress notes documented by 42 attending providers. These notes were for patients with the 5 most common primary International Statistical Classification of Diseases and Related Health Problems, version 10, parent codes for each provider. For the manual review, 120 notes from 8 providers were randomly sampled. Main outcome measurements were characters or number of words in each note categorized by attribution source, author type, and time of creation.

Results: Imported text entries made up the majority of text in new and return patients, 2,978 characters (77%) and 3,612 characters (91%). Support staff members authored substantial portions of notes; 3,024 characters (68%) of new patient notes, 3,953 characters (83%) of return patient notes. Finally, providers completed large amounts of documentation after clinical visits: 135 words (35%) of new patient notes, 102 words (27%) of return patient notes.

Conclusions: EHR documentation consists largely of imported text, is often authored by support staff, and is often written after the end of a visit. These findings raise questions about documentation accuracy and utility and may have implications for quality of care and patient-provider relationships.

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http://dx.doi.org/10.1016/j.ajo.2019.11.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7073273PMC
March 2020

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