Data become information when it can be accessed and analyzed. A patient record that is illegible or inaccessible provides no benefit to the patient and no information to the provider. Data gathered but not recorded by one party cannot be used by another to develop a plan of treatment or justify a level of service.
The Computer-Based Ophthalmic Recordkeeping (COR) System grew out of a desire to have ready access to patient information, improved legibility and uniformity of charting in a training environment with frequent team turnover, and faster communication with the referral source. These goals were achieved by developing a computer program for networked computers to provide for text entry of patient data by each eye care team member.
Patient data is entered at each phase of the encounter and is immediately available to the next provider. At the end of the clinical session, a report is printed and mailed within 24 hours of the patient encounter, or faxed that day if the situation warrants. Previous computer systems for eye care have concentrated on recording the diagnoses of patients1'3 but not report generation.
While complete elimination of the paper record might be desirable, it is not currently feasible for both technical and legal reasons.4 A paper record is permanent, with a life expectancy exceeding that of the patient, and not subject to the technological Ufe cycle of computer systems. A paper record, signed by the provider, is a legal document, by itself the definitive record of the physician's observations and plans. With few exceptions, the patient record is a paper chart stored in a central facility. Preparation of a paper report by the COR System is essential if the report is to be included in the existing paper-based patient record. It is unlikely in the immediate future that the need for a paper document will be eliminated. However, if the information recorded on the document also is stored in a central computer accessible by any qualified provider with a computer terminal, the need to have physical access to the paper record is reduced.
The COR System has been used at our institution for all pediatric ophthalmology patient recordkeeping since May 1993. Because we found no commercial system for recording the motility examination, we developed the COR System ourselves. The system stores all the text entries associated with a complete ophthalmic examination. Optimum use of the COR System requires a network of 386-class MS-DOS personal computers. Detailed system requirements are listed in Table 1.
Computer Requirements for the COR System
The COR System allows flexibility in the preparation of the ophthalmic record (as much text as desired may be entered in narrative fields), structure (the main headings of the ophthalmic examination are automatically generated), and automation (as much as possible, the data entry process is facilitated through the use of pull-down screens, user-defined default descriptions of normal examination elements, and forward copying of the entry from the prior examination for editing).
The categories of information recorded are listed in Table 2. Numeric data (such as refraction) are recorded in a fixed format. Narrative fields, such as a description of the slit-lamp examination, are entered in text windows that provide word-wrap and unlimited field length.
Two categories of data warrant specific mention. First, procedures are coded using the American Medical Association Current Procedural Terminology (CPT) coding system.5 A sample database of 25 CPT codes is included with the system for illustration purposes. Users may enter any additional codes they desire for their own use, but may not distribute the list to third parties. Up to five procedures may be coded for each encounter.
Diagnoses are coded according to the Wilmer Information System (WIS),3 an extension of the International Classification of Diseases (ICD-9-CM).6 The WIS extensions subclassify the ICD-9-CM ###.## code structure to include one or more additional decimal places, and are selected such that when the additional decimal places are truncated, the remaining code maps to the appropriate ICD-9-CM code for billing purposes. Up to 5 CPT codes may be recorded for each encounter.
Just as a patient record may involve several pages of paper, sometimes not all of the information will fit on the computer screen. The COR System uses a low-resolution character display mode (25 rows by 80 columns) and a windowing system to access tile data in individual headings. These windows are small and minimize obstruction of the main screen. All headings are available from the main screen, minimizing the amount of time spent traversing through nested screens.
Figure 1 shows tile layout of the data entry screen. The first 30 characters of a field are shown beside the heading. To add or edit the contents of a heading, the mouse is used to select the heading and the edit window appears. The edit window supports word-wrap and scrolling.
Data Types stored by the COR System
The COR System automates the preparation of reports for distribution. Default recipients (eg, Medical Records, Clinic Chart) can be defined, and a copy of the report automatically printed for them. Copies are automatically printed for each report recipient listed in the "referred by" fields.
A cover letter for each recipient also may be printed to facilitate mailing the reports. A cover letter can be placed with the report in a window envelope, eliminating the need to address an envelope.
The layout of the report may be customized to meet local specifications by modification of a configuration file. The cover letter may be printed on letterhead stationery or on plain paper, allowing for the interleaving of reports and cover letters.
Figure 1: Layout of the data entry screen. A mouse or other pointing device is used to select one of the listed headings, opening a popup window to allow data entry. An empty record is shown. Records that have data stored in a field will have the first 30 characters of the field displayed to the right of the heading.
Figure 2: Sample output of the COR System. The report, cover letter, and window envelope are shown. The individual user of the COR System may change the identification blocks as desired.
The COR System is written in the FoxPro programming language, and compiled and distributed as an MS-DOS EXE file that does not require the pin-chase of any additional software. The COR System allows for patient retrieval by provider, date of service, and patient name. More complex searches can be performed by searching the COR System database files from within FoxPro by use of the menu-driven FoxPro user interface. In this manner, custom reports can be generated without the need to learn a programming language. The COR System files are in an industry standard DBF format that can be read by a multitude of other database systems as well.
The consultation note generated by the COR System is shown in Figure 2. The example is prepared from a report of a complex case of strabismus.7 Headings that have not had data entered are not printed. The cover letter is also shown in Figure 2. The letterhead layout may be changed by the user. The contents of the cover letter are identical for each patient.
The disk storage requirements of the COR System are modest. Approximately five megabytes (MB) of storage are required to load the base program. Additional storage is required to store patient demographics (approximately one kilobytes [KB] per patient) and examination (approximately three KB per patient encounter).
Approximately 25 MB of disk storage would be required each year to hold 100 patient encounters per week using the text-based database of the COR System. Disk storage requirements of this size will allow the entire database to remain available at all times, even allowing for continued use over a decade. However, this would not be the case if images were incorporated in the database. Images are typically stored on an expanding number of removable optical disks. Viewing the images of a given patient requires manual insertion of a disk into the computer, analogous to retrieving a paper record from a file cabinet. Such a process allows online access to image data at all times from anywhere on the network.
Whatever the report format, if it is impractical to enter the required data, the system will not be used. Despite the effort expended, if the report is not found useful by the report recipient, the system is a failure. How is the COR System perceived by the users of the system and the recipients of the reports?
Experience at our institution suggests that individuals with computer experience prefer the system to pen and paper charting. Our technicians find that similar amounts of time are required to chart or enter numeric data, such as refractions, or history elements, where paraphrased typing can occur while the patient is talking. New users can be oriented to use of the system in about 5 minutes, and are soon entering clinical observations at rates limited only by their typing speed. Ultimately, the acceptance of the COR System will hinge upon whether the practitioner can maintain productivity in the clinic. Our experience suggests that it is the final entry of impressions and plan that is the limiting step; methods of increasing efficiency in this area are being studied.
Impressions and plan can be entered either directly by the physician or dictated and later transcribed; dictation typically takes less than a minute and transcription about two. Even if only impressions and plan (rather than the entire note) are transcribed, there is still a drastic reduction in the amount of typing required by the transcriptionist, resulting in increased cost effectiveness and timeliness.
There are powerful and compelling reasons to use a network of computers to record the patient encounter. A printed note that is available at the conclusion of the patient encounter can improve communication with both the patient and the referring physician. Access to patient records from any workstation on the network allows questions to be answered without the need to manually pull a chart.
The paper output that the COR System produces, once signed by the provider, is the substantive record. The paper record has permanence, is universally accepted, and does not require any special equipment to access. Some form of patient chart is required to store correspondence, photographs, and drawings. In the event that the COR System is adopted and later abandoned, the legacy that it would leave behind is a legible paper record. Should a computer failure occur, the paper record is still available, and patient encounter data can be recorded with pen and paper.
The COR System is a robust computer program, the product of 3 years of development at our institution. It has been found easy to use by our attendings, residents, technicians, and medical students. An executable version of the COR System is available from the author at no charge.
To obtain a copy of the COR System, please contact the author. The COR System is distributed as is, with no warranties expressed or implied. While future updates are anticipated, they are not guaranteed. It is the responsibility of the provider to read and verify the accuracy of the note that is produced. The COR System is provided with the hope that patient care will be enhanced and productivity improved.
1. Miller JM, Thompson JT, Caprioli J. Computerized database to identify patient populations for clinical research. Ophthalmology - 1988;95(suppl):6-10.
2. Soroka M. The development of a standardized data base at the University Optometric Center of the State College of Optometry State University of New York. Am J Optom Physiol Opt. 1982;59:469-477.
3. Miller KM, Wisnicki HJ, Buchman JP, et al. The Wilmer Information System - a classification and retrieval system for information on diagnosis and therapy in ophthalmology. Ophthalmology. 1988;95:403-409.
4. Waller AA. Legal aspects of computer-based patient records and record systems. In: Dick RS, Steen EB, eds. The Computer-based Patient Record: An Essential Technology for Health Care. Washington, DC: National Academy Press; 1991:156-179.
5. American Medical Association. Physicians' Current Procedural Terminology: CPT '94. Chicago, Dl: American Medical Association; 1993.
6. World Health Organization. The International Classification of Diseases, Clinical Modification: ICD.9.CM, 9th ed. Ann Arbor, Mich: Commission on Professional and Hospital Activities; 1978.
7. Kushner BJ. A case of paretic strabismus with monocular cataract resulting in fixation with the paretic eye. Binocular Vision and Eye Muscle Surgery Quarterly. 1994;9:32-37.
Computer Requirements for the COR System
Data Types stored by the COR System