Overcoming obstacles to collecting narrative data from eye care professionals at the point-of-care.
Capturing the nuances of clinical observations in an electronic format has been a major challenge in implementing electronic health records. In a formative evaluation study using three different methodologies, we identified that the greatest obstacle to point-of-care data entry for eye care was supporting free text annotation of clinical observations. To overcome this obstacle, we developed an approach that captures an image of a free text entry and associates this image with related data elements in an encounter note. Through simulated patient studies, we observed that this approach successfully supported complex documentation at the point of care by clinicians.
Silvey
Garry M
GM
Division of Clinical Informatics, Department of Community and Family Medicine, Duke University Medical Center, Durham, NC, USA.
Lobach
David F
DF
Macri
Jennifer M
JM
Hunt
Megan
M
Kacmaz
Roje O
RO
Lee
Paul P
PP
D001292:Attitude to Computers; D017144:Focus Groups; D006801:Humans; D016347:Medical Records Systems, Computerized; D008838:Microcomputers; D009885:Ophthalmology; D009907:Optometry; D019095:Point-of-Care Systems; D014584:User-Computer Interface