Table 1.
Special Requirements for Electronic Health Record Systems in Ophthalmology. Certification by the Office of the National Coordinator for “meaningful use” as an EHR system is a given essential. Items are classified either as “essential” for current systems or as “desirable” for current systems and essential for future systems.
| Function | Essential | Desirable |
|---|---|---|
| Clinical documentation | ||
| Enable entry and storage of all ophthalmology-specific data required to support American Academy of Ophthalmology Preferred Practice Patterns | X | |
| Organize ophthalmology-specific elements separately (e.g., past ocular history, ocular medications) | X | |
| Conform or map to vendor-neutral standard terminologies (e.g., SNOMED CT, ICD) to represent problem lists | X | |
| Conform or map to RxNorm to represent medications | X | |
| Conform or map to vendor-neutral standard terminologies (e.g., SNOMED CT) to represent: | ||
| Diagnoses and procedures | X | |
| Allergies and clinical findings | X | |
| Enable physicians and technicians to keep multiple records open simultaneously and securely in different rooms, with easy reauthentication | X | |
| Provide tools for incorporating color drawing, including ocular templates | X | |
| Analyze clinical workflow before and after EHR implementation | X | |
| Exchange full set of ophthalmic clinical data with EHRs from other vendors | X | |
| Link clinical documentation to billing and charge capture and integrate with practice management | X | |
| Allow physician to review patient information easily before entering room | X | |
| Ophthalmic vital signs and laboratory studies | ||
| Record visual acuity and refractive discrete elements in accordance with DICOM Supplement 130 | X | |
| Record intraocular pressure as a discrete data element | X | |
| Display and graph visual acuity and intraocular pressure over time | X | |
| Medical and surgical management | ||
| Electronically associate all preoperative, operative, and postoperative documents | X | |
| Support documentation of office-based and operating room procedures | X | |
| Allow physician to generate operative report at time of surgery | X | |
| Ophthalmic measurement and imaging devices | ||
| Conform to vendor-neutral standards (e.g., DICOM) for receipt and representation of data from all ophthalmic instruments and devices | X | |
| Conform to vendor-neutral standards and profiles for ordering ophthalmic imaging and measurement studies (e.g., DICOM Modality Worklist and IHE Eye Care Workflow) | X | |
| Document completion and interpretation of ophthalmic imaging and measurement studies | X | |
| Request, retrieve, display, and communicate all imaging and measurement data generated by ophthalmic instruments in a standard vendor-neutral format (e.g., DICOM) | X | |
| Manage all ophthalmic imaging data in vendor-neutral format (e.g., DICOM) or provide tight integration with external PACS in vendor-neutral format | X |
DICOM = Digital Imaging and Communications in Medicine; EHR = electronic health record; ICD = International Classification of Diseases; IHE = Integrating the Healthcare Enterprise; PACS = Picture Archiving and Communication System; SNOMED CT = Systematized Nomenclature of Medicine-Clinical Terms.