title: eHealth 2015 Special Issue: Impact of Electronic Health Records on the Completeness of Clinical Documentation Generated during Diabetic Retinopathy Consultations.
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.
  
  
  OBJECTIVE
  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.
authors.affiliation: Medical University of Vienna , Department of Ophthalmology and Optometrics, Vienna, Austria.
authors.forename: C
authors.initials: C
authors.lastname: Mitsch
authors.affiliation: Medical University of Vienna , Department of Ophthalmology and Optometrics, Vienna, Austria.
authors.forename: P
authors.initials: P
authors.lastname: Huber
authors.affiliation: Medical University of Vienna , Department of Ophthalmology and Optometrics, Vienna, Austria.
authors.forename: K
authors.initials: K
authors.lastname: Kriechbaum
authors.affiliation: Medical University of Vienna , Department of Ophthalmology and Optometrics, Vienna, Austria.
authors.forename: C
authors.initials: C
authors.lastname: Scholda
authors.affiliation: Medical University of Vienna , Center for Medical Statistics, Informatics, and Intelligent Systems, Vienna, Austria.
authors.forename: G
authors.initials: G
authors.lastname: Duftschmid
authors.affiliation: Medical University of Vienna , Center for Medical Statistics, Informatics, and Intelligent Systems, Vienna, Austria.
authors.forename: T
authors.initials: T
authors.lastname: Wrba
authors.affiliation: Medical University of Vienna , Department of Ophthalmology and Optometrics, Vienna, Austria.
authors.forename: U
authors.initials: U
authors.lastname: Schmidt-Erfurth
mesh_terms: D003930:Diabetic Retinopathy; D004282:Documentation; D057286:Electronic Health Records; D006801:Humans; D011786:Quality Control; D012017:Referral and Consultation; D017216:Telemedicine
keywords: Care records; Electronic health records and systems; Encounter notes; Ophthalmology; Testing and evaluation