CHICAGO — The postoperative medical reconciliation for ophthalmic medications after resident-performed cataract surgery was incorrect for a surprising number of patients, a new study shows.
In fact, the investigators found that less than half of the electronic medical records were complete and free of errors.
“The implications are huge,” said senior investigator Jayne Weiss, MD, from the Louisiana State University School of Medicine in New Orleans. “The reality of the accuracy is not something that people are looking at,” she told Medscape Medical News.
This is the first study of electronic records in ophthalmology we could find, said her coinvestigator, Julie Kumata, MD, also from Louisiana State University.
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The team presented results from their retrospective review of electronic records during the poster session here at the American Academy of Ophthalmology 2014 Annual Meeting.
For their study, they reviewed all 258 patients who underwent resident-performed cataract surgery in a single hospital over a 1-year period.
They found that slightly more than one-third of the electronic medical records they assessed were complete and accurate.
Table. Accuracy of the Electronic Medical Records
Status | Number | Percent
Correct | 94 | 36.4
Omissions | 153 | 59.3
Errors | 3 | 1.2
Omissions and errors | 8 | 3.1
Dr Weiss said she does not think these problems are unique to her institution. “I expect all places have a level of error,” she said. Louisiana State University has had an electronic medical record system since 2003, so the problems do not reflect a learning curve, she pointed out.
“The bottom line is that the questions need to be asked,” said Anat Galor, MD, from the Bascom Palmer Eye Institute in Miami, who was not involved in the study. Electronic records “are not perfect, and we need to recognize that,” she told Medscape Medical News.
Dr Galor pointed out that electronic records are like manual medical records, in that someone still has to enter the data into the file. As with any system, it has pros and cons. “I think if you looked at the medical chart, you would see the same thing,” she said. She described the electronic records as “an evolving system.”
She acknowledged, however, that electronic records promote clicking, and that the clicking can result in entering the wrong information. She said she advises her residents that “if you are going to cut and paste, please read what you cut and paste.”
Dr Galor said the take-home message from the poster is that “making electronic medical records better is worth everyone’s time.”
An even stronger opinion on the subject was expressed by Lance Turkish, MD, an ophthalmologist in private practice in New Orleans.
“The government mandate is forcing physicians to accept programs that aren’t in the best interest of the patient,” he told Medscape Medical News.
Dr Weiss said she agrees. She explained that electronic records have increased the amount of time required to document the patient visit. She also noted that physicians “know that maybe, after a period of time, what you are looking at in the record isn’t true.”
There has been a large financial investment in electronic systems, which can influence the criticisms that physicians are willing to make, Dr Weiss added.
Dr Weiss, Dr Kumata, Dr Galar, and Dr Turkish have disclosed no relevant financial relationships.
American Academy of Ophthalmology (AAO) 2014 Annual Meeting: Abstract PO081. Presented October 19, 2014.
Date: November 06, 2014