AAO offers EHR checklist for ophthalmology
The field of ophthalmology has a number of unique features compared with other medical and surgical specialties regarding clinical workflow and data management, according to an article published by the American Academy of Ophthalmology (AAO) in Ophthalmology online.
The article, authored by the San Francisco-based AAO's Medical IT Committee (MITC), presented a list of the special requirements needed to make EHR systems intuitive and efficient for ophthalmology practices.
“Ophthalmologists often lament the absence of these specialty-specific features in EHRs, particularly in systems that were developed originally for primary care physicians or other medical specialists,” wrote MITC Chair Michael F. Chiang, MD, from the departments of ophthalmology and of medical informatics and clinical epidemiology at the Oregon Health & Science University in Portland, and colleagues.
The paper includes the list of 17 "essential" and six "desirable" features in the areas of clinical documentation, ophthalmic vital signs and laboratory studies, medical and surgical management, and ophthalmic measurement and imaging devices.
Among the 17 essentials were enabling entry and storage of all ophthalmology-specific data required to support AAO Preferred Practice Patterns; organizing ophthalmology-specific elements (such as past ocular history and ocular medications) separately; and conforming or mapping to vendor-neutral standard terminologies such as SNOMED CT or ICD to represent problem lists. Some desirable features were allergies and clinical findings, exchange of a full set of ophthalmic clinical data with EHRs from other vendors and allowing physicians to easily review patient information before an encounter.
The guidelines are intended to be used by ophthalmologists and their staffs to help identify important features when searching for EHR systems, according to the authors.
The recommendations addressed how an EHR system should accommodate certain areas of ophthalmic practice, including:
“The American Academy of Ophthalmology believes that these functions are elements of good system design that will improve access to relevant information at the point of care between the ophthalmologist and the patient, will enhance timely communications between primary care providers and ophthalmologists, will mitigate risk and ultimately will improve the ability of physicians to deliver the highest-quality medical care,” the authors concluded.
The article, authored by the San Francisco-based AAO's Medical IT Committee (MITC), presented a list of the special requirements needed to make EHR systems intuitive and efficient for ophthalmology practices.
“Ophthalmologists often lament the absence of these specialty-specific features in EHRs, particularly in systems that were developed originally for primary care physicians or other medical specialists,” wrote MITC Chair Michael F. Chiang, MD, from the departments of ophthalmology and of medical informatics and clinical epidemiology at the Oregon Health & Science University in Portland, and colleagues.
The paper includes the list of 17 "essential" and six "desirable" features in the areas of clinical documentation, ophthalmic vital signs and laboratory studies, medical and surgical management, and ophthalmic measurement and imaging devices.
Among the 17 essentials were enabling entry and storage of all ophthalmology-specific data required to support AAO Preferred Practice Patterns; organizing ophthalmology-specific elements (such as past ocular history and ocular medications) separately; and conforming or mapping to vendor-neutral standard terminologies such as SNOMED CT or ICD to represent problem lists. Some desirable features were allergies and clinical findings, exchange of a full set of ophthalmic clinical data with EHRs from other vendors and allowing physicians to easily review patient information before an encounter.
The guidelines are intended to be used by ophthalmologists and their staffs to help identify important features when searching for EHR systems, according to the authors.
The recommendations addressed how an EHR system should accommodate certain areas of ophthalmic practice, including:
- Supporting documentation in and transitions between the ophthalmologist's office and the operating room;
- Capturing, tracking and displaying "vital signs of the eye," such as visual acuity; and
- Incorporating hand-drawn sketches or annotations into records.
“The American Academy of Ophthalmology believes that these functions are elements of good system design that will improve access to relevant information at the point of care between the ophthalmologist and the patient, will enhance timely communications between primary care providers and ophthalmologists, will mitigate risk and ultimately will improve the ability of physicians to deliver the highest-quality medical care,” the authors concluded.