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

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. Citation: Mitsch C, Huber P, Kriechbaum K, Scholda C, Duftschmid G, Wrba T, Schmidt-Erfurth U. Impact of Electronic Health Records on the Completeness of Clinical Documentation Generated during Diabetic Retinopathy Consultations. Appl Clin Inform 2015; 6: 478–487 http://dx.doi.org/10.4338/ACI-2015-03-RA-0028