Implemented lessons learned from Office Record Review into EMR templates and went live same day.


The American Board of Ophthalmology introduced mandatory re-certification every 10 years the year I became a 'Board Certified' Ophthalmologist in 1995. The re-certification process is now spread out over 8 years and I just completed the first phase of my second 10-year re-certification process: the Office Record Review (ORR.) I had not remembered the specifics from the last time I had completed the exercise but remembered that I felt it was an educational exercise. Now with it once again completed, I still feel it is a rewarding experience.

Although bound to not reveal any details of the questions, I would like to discuss the publicly posted facts about the process, describe the experience of carrying out the Office Record Review, and describe how I have already implemented what I learned from the process into our Electronic Medical Record just one day after completing the ORR in order to better care for my patients.

The medico-legal standard dictum that we must live by is that if something is not documented then it did not happen. Although it does not mean it didn't happen, with out that bit of proof by proper documentation, there is no way to prove something happened in a medical encounter. Legal advice is that when it comes down to the word of a patient against the word of a doctor, then the patient is given the benefit of the doubt. Not only is it important medico-legally to provide proper documentation in the medical record, but it assures best practice patterns. Any physician who picks up your chart should be able to follow the line of reasoning for why a patient was diagnosed with their condition, why you are providing a given medical or surgical intervention and what your follow-up plans might be. For all these reasons, the ABO ORR is a thorough check of proper documentation.

The ABO's Maintenance of Certification program is documented for all to see at their site. There are 37 modules for the practicing board-certified ophthalmologist to choose from for the Evaluation of Practice Performance part of the process in the form of this Office Record Review. I had to choose 3 of these 37 types of patient problems that presents to ophthalmologists and identify 5 patients with each of these problems in my practice. Once unique identifying data is provided on-line, keeping patient anonymous to the Board, the choice of patients cannot be altered. In other words, if not doing well you can't pick different patients. For each patient, there are a series of questions that must be answered as either Documented or Not Documented. Very rarely is there a Not Applicable option. In other words, items that do not have the n/a option, you know are important to document in the chart. 

Once all the chart reviews are completed, you have to submit the data. What came as a surprise this time 'round, was that feedback was provided immediately on-line with a score for each module and highlighted sections of standards of care to emphasize why certain things are important. Overall, I would have to say that most things I had documented but there were some items for which I definitely did do but was not documenting as they were just so routine. However, remember that dictum, if it is not documented then it didn't happen.

Fortunately, my Electronic Medical Record system is quite customizable without assistance from the vendor. I was able to discuss the documentation deficiencies with my staff and one of my technicians began to make changes to our EMR examination forms to assure proper documentation for all future patients. Also, an extra bit of information was added to the home screen for each patient to readily assure something was more obvious for each patient. Is this something you can do with your EMR?

I would appreciate any comments regarding self-assessment exercises like this and also whether your EMR easily allows you to alter examination templates and implement these changes right away like we were able to do in order to not just improve documentation but also provided a better standard of care.