title: 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.
  
  
  METHODS
  Comparative case series.
  
  
  METHODS
  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.
  
  
  METHODS
  (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.
  
  
  BACKGROUND
  The author(s) have no proprietary or commercial interest in any materials discussed in this article.
authors.affiliation: Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon 97239, USA.
authors.forename: David S
authors.initials: DS
authors.lastname: Sanders
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Lattin
authors.forename: Sarah
authors.initials: S
authors.lastname: Read-Brown
authors.forename: Daniel C
authors.initials: DC
authors.lastname: Tu
authors.forename: David J
authors.initials: DJ
authors.lastname: Wilson
authors.forename: Thomas S
authors.initials: TS
authors.lastname: Hwang
authors.forename: John C
authors.initials: JC
authors.lastname: Morrison
authors.forename: Thomas R
authors.initials: TR
authors.lastname: Yackel
authors.forename: Michael F
authors.initials: MF
authors.lastname: Chiang
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015862:Choroid Diseases / Q000175:diagnosis*; D003941:Diagnostic Techniques, Ophthalmological; D004282:Documentation / Q000379:methods / Q000592:standards*; D057286:Electronic Health Records / Q000592:standards*; D005260:Female; D005902:Glaucoma, Open-Angle / Q000175:diagnosis*; D006801:Humans; D008268:Macular Degeneration / Q000175:diagnosis*; D008297:Male; D008875:Middle Aged; D009885:Ophthalmology; D010209:Paper; D010808:Physical Examination