Electronic Health Records in Ophthalmology: Source and Method of Documentation

Bradley S. Henriksen, Isaac H. Goldstein, Adam Rule, Abigail E. Huang, Haley Dusek, Austin Igelman, Michael F. Chiang, Michelle R. Hribar

Research output: Contribution to journalArticle

Abstract

Purpose: This study analyzed and quantified the sources of electronic health record (EHR) text documentation in ophthalmology progress notes. Design: EHR documentation review and analysis. Methods: SETTING: a single academic ophthalmology department. STUDY POPULATION: a cohort study conducted between November 1, 2016, and December 31, 2018, using secondary EHR data and a follow-up manual review of a random samples. The cohort study included 123,274 progress notes documented by 42 attending providers. These notes were for patients with the 5 most common primary International Statistical Classification of Diseases and Related Health Problems, version 10, parent codes for each provider. For the manual review, 120 notes from 8 providers were randomly sampled. Main outcome measurements were characters or number of words in each note categorized by attribution source, author type, and time of creation. Results: Imported text entries made up the majority of text in new and return patients, 2,978 characters (77%) and 3,612 characters (91%). Support staff members authored substantial portions of notes; 3,024 characters (68%) of new patient notes, 3,953 characters (83%) of return patient notes. Finally, providers completed large amounts of documentation after clinical visits: 135 words (35%) of new patient notes, 102 words (27%) of return patient notes. Conclusions: EHR documentation consists largely of imported text, is often authored by support staff, and is often written after the end of a visit. These findings raise questions about documentation accuracy and utility and may have implications for quality of care and patient-provider relationships.

Original languageEnglish (US)
JournalAmerican journal of ophthalmology
DOIs
StateAccepted/In press - Jan 1 2020

Fingerprint

Electronic Health Records
Ophthalmology
Documentation
Cohort Studies
Quality of Health Care
International Classification of Diseases

ASJC Scopus subject areas

  • Ophthalmology

Cite this

Henriksen, B. S., Goldstein, I. H., Rule, A., Huang, A. E., Dusek, H., Igelman, A., ... Hribar, M. R. (Accepted/In press). Electronic Health Records in Ophthalmology: Source and Method of Documentation. American journal of ophthalmology. https://doi.org/10.1016/j.ajo.2019.11.030

Electronic Health Records in Ophthalmology : Source and Method of Documentation. / Henriksen, Bradley S.; Goldstein, Isaac H.; Rule, Adam; Huang, Abigail E.; Dusek, Haley; Igelman, Austin; Chiang, Michael F.; Hribar, Michelle R.

In: American journal of ophthalmology, 01.01.2020.

Research output: Contribution to journalArticle

Henriksen, Bradley S. ; Goldstein, Isaac H. ; Rule, Adam ; Huang, Abigail E. ; Dusek, Haley ; Igelman, Austin ; Chiang, Michael F. ; Hribar, Michelle R. / Electronic Health Records in Ophthalmology : Source and Method of Documentation. In: American journal of ophthalmology. 2020.
@article{9eb4a6bbc05f48b9956058b09dc34610,
title = "Electronic Health Records in Ophthalmology: Source and Method of Documentation",
abstract = "Purpose: This study analyzed and quantified the sources of electronic health record (EHR) text documentation in ophthalmology progress notes. Design: EHR documentation review and analysis. Methods: SETTING: a single academic ophthalmology department. STUDY POPULATION: a cohort study conducted between November 1, 2016, and December 31, 2018, using secondary EHR data and a follow-up manual review of a random samples. The cohort study included 123,274 progress notes documented by 42 attending providers. These notes were for patients with the 5 most common primary International Statistical Classification of Diseases and Related Health Problems, version 10, parent codes for each provider. For the manual review, 120 notes from 8 providers were randomly sampled. Main outcome measurements were characters or number of words in each note categorized by attribution source, author type, and time of creation. Results: Imported text entries made up the majority of text in new and return patients, 2,978 characters (77{\%}) and 3,612 characters (91{\%}). Support staff members authored substantial portions of notes; 3,024 characters (68{\%}) of new patient notes, 3,953 characters (83{\%}) of return patient notes. Finally, providers completed large amounts of documentation after clinical visits: 135 words (35{\%}) of new patient notes, 102 words (27{\%}) of return patient notes. Conclusions: EHR documentation consists largely of imported text, is often authored by support staff, and is often written after the end of a visit. These findings raise questions about documentation accuracy and utility and may have implications for quality of care and patient-provider relationships.",
author = "Henriksen, {Bradley S.} and Goldstein, {Isaac H.} and Adam Rule and Huang, {Abigail E.} and Haley Dusek and Austin Igelman and Chiang, {Michael F.} and Hribar, {Michelle R.}",
year = "2020",
month = "1",
day = "1",
doi = "10.1016/j.ajo.2019.11.030",
language = "English (US)",
journal = "American Journal of Ophthalmology",
issn = "0002-9394",
publisher = "Elsevier USA",

}

TY - JOUR

T1 - Electronic Health Records in Ophthalmology

T2 - Source and Method of Documentation

AU - Henriksen, Bradley S.

AU - Goldstein, Isaac H.

AU - Rule, Adam

AU - Huang, Abigail E.

AU - Dusek, Haley

AU - Igelman, Austin

AU - Chiang, Michael F.

AU - Hribar, Michelle R.

PY - 2020/1/1

Y1 - 2020/1/1

N2 - Purpose: This study analyzed and quantified the sources of electronic health record (EHR) text documentation in ophthalmology progress notes. Design: EHR documentation review and analysis. Methods: SETTING: a single academic ophthalmology department. STUDY POPULATION: a cohort study conducted between November 1, 2016, and December 31, 2018, using secondary EHR data and a follow-up manual review of a random samples. The cohort study included 123,274 progress notes documented by 42 attending providers. These notes were for patients with the 5 most common primary International Statistical Classification of Diseases and Related Health Problems, version 10, parent codes for each provider. For the manual review, 120 notes from 8 providers were randomly sampled. Main outcome measurements were characters or number of words in each note categorized by attribution source, author type, and time of creation. Results: Imported text entries made up the majority of text in new and return patients, 2,978 characters (77%) and 3,612 characters (91%). Support staff members authored substantial portions of notes; 3,024 characters (68%) of new patient notes, 3,953 characters (83%) of return patient notes. Finally, providers completed large amounts of documentation after clinical visits: 135 words (35%) of new patient notes, 102 words (27%) of return patient notes. Conclusions: EHR documentation consists largely of imported text, is often authored by support staff, and is often written after the end of a visit. These findings raise questions about documentation accuracy and utility and may have implications for quality of care and patient-provider relationships.

AB - Purpose: This study analyzed and quantified the sources of electronic health record (EHR) text documentation in ophthalmology progress notes. Design: EHR documentation review and analysis. Methods: SETTING: a single academic ophthalmology department. STUDY POPULATION: a cohort study conducted between November 1, 2016, and December 31, 2018, using secondary EHR data and a follow-up manual review of a random samples. The cohort study included 123,274 progress notes documented by 42 attending providers. These notes were for patients with the 5 most common primary International Statistical Classification of Diseases and Related Health Problems, version 10, parent codes for each provider. For the manual review, 120 notes from 8 providers were randomly sampled. Main outcome measurements were characters or number of words in each note categorized by attribution source, author type, and time of creation. Results: Imported text entries made up the majority of text in new and return patients, 2,978 characters (77%) and 3,612 characters (91%). Support staff members authored substantial portions of notes; 3,024 characters (68%) of new patient notes, 3,953 characters (83%) of return patient notes. Finally, providers completed large amounts of documentation after clinical visits: 135 words (35%) of new patient notes, 102 words (27%) of return patient notes. Conclusions: EHR documentation consists largely of imported text, is often authored by support staff, and is often written after the end of a visit. These findings raise questions about documentation accuracy and utility and may have implications for quality of care and patient-provider relationships.

UR - http://www.scopus.com/inward/record.url?scp=85077919457&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85077919457&partnerID=8YFLogxK

U2 - 10.1016/j.ajo.2019.11.030

DO - 10.1016/j.ajo.2019.11.030

M3 - Article

C2 - 31811860

AN - SCOPUS:85077919457

JO - American Journal of Ophthalmology

JF - American Journal of Ophthalmology

SN - 0002-9394

ER -