Electronic Health Records in Ophthalmology: Source and Method of Documentation

Area of Science:

• Ophthalmology
• Health Informatics
• Medical Documentation

Background:

• Electronic health records (EHRs) are crucial for patient care and medical research.
• Understanding the composition and authorship of EHR documentation is essential for evaluating its quality and utility.
• Ophthalmology progress notes represent a significant volume of clinical documentation.

Purpose of the Study:

• To analyze and quantify the sources of text documentation within ophthalmology progress notes in EHR systems.
• To identify the primary contributors and timing of documentation entries.

Main Methods:

• A cohort study utilizing secondary EHR data from an academic ophthalmology department.
• Analysis of 123,274 progress notes from 42 attending providers over a two-year period.
• Manual review of 120 randomly sampled notes to categorize text by source, author, and creation time.

Main Results:

• Imported text constituted the majority of EHR notes (77% for new patients, 91% for return patients).
• Support staff authored a substantial portion of the documentation (68% for new patients, 83% for return patients).
• Providers completed significant documentation after clinical visits (35% for new patients, 27% for return patients).

Conclusions:

• Ophthalmology EHR documentation is predominantly composed of imported text and authored by support staff.
• A significant amount of documentation occurs after patient encounters, raising questions about accuracy and utility.
• Findings suggest potential implications for the quality of care and patient-provider relationships due to documentation practices.