Eye Care Documentation Template

Description

The Veterans Health Administration seeks to standardize eye care data output from routine clinical documentation in support of quality clinical care delivery, performance improvement, interoperability across health care platforms, and clinical research activities. Prototype work has been done in both the DoD/VA Vision Center of Excellence (Optimal Vision Care Prototype) and the VA (Eye Care SmartForm) to define eye care documentation requirements and to promote standardized data output. While not yet implemented in the VA, this draft documentation template content goes a step farther than earlier projects by conforming to HL7 standards for clinical decision support, furthering the aim of an easily shareable tool with shareable data output from routine clinical documentation.

Artifact Type
Creation Date
Version
0.1
Unique Identifier
045fc473-16ee-5d98-ba99-830f628ba865
Status
Experimental
True

Artifact Creation and Usage

Contributors
Linda Wedemeyer, MD, Ophthalmologist/Physician Informatician Knowledge Based Systems, Office of Health Informatics Los Angeles, CA
Mary Lynch, MD, Ophthalmologist Atlanta VA Medical Center (VAMC) Atlanta, GA
Rex Ballinger, OD, Optometrist Baltimore VAMC Baltimore, MD
Thomas Garrido, OD, Optometrist, Scott Air Force Base, IL
David Eliason, MD, Ophthalmologist and Deputy Director, Vision Center of Excellence Martinsburg VAMC, Martinsburg, WV
Kristin Biggerstaff, MD, Ophthalmologist and Glaucoma Specialist, Michael E. DeBakey VAMC, Houston, TX
Matthew Cordes, OD, Chief of Optometry, The Villages VA Outpatient Clinic, North Florida/South Georgia Veterans Health System, The Villages, FL
License
IP Attestation The author asserts that this artifact has been developed in compliance with the intellectual property rights attributed to the source material.
Copyrights

Copyright © 2018 Veterans Health Administration, Department of Veterans Affairs. All rights reserved. Contributions from external parties are property of respective copyright holders.

MeSH Topics
Repository Information
Publication Date
Last Review Date
Knowledge Level

Structured code that is interpretable by a computer (includes data elements, value sets, logic)

Purpose and Usage
Usage
Target User
Provider in an Ophthalmology or Optometry clinic
Patient Age Group
Adult patients
Workflow Setting
Eye Care
Clinical Venue
Outpatient

 

Cautions

THE CLINICAL CONTENT IN THIS DOCUMENT IS NOT DIRECTLY SUITABLE FOR CLINICAL USE AS PRESENTED SINCE IT HAS NOT BEEN TESTED IN A CLINICAL ENVIRONMENT. IT HAS NEVER BEEN PILOTED, NEVER 100% REPRESENTS THE INTENT OF THE CLINICAL SUBJECT MATTER EXPERTS, AND MAY CAUSE HARM IF APPLIED AS-IS. THIS WORK IS MADE AVAILABLE WITHOUT ANY WARRANTY WHATSOEVER, AND WITHOUT CLAIMS, EXPRESSED OR IMPLIED, OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE.

Supporting Evidence
Source Description
Derived From
Eye Care Clinical Content White Paper
Associated Resource
Eye Care Documentation Template Conceptual Structure Document
Associated Resource
Eye Care Documentation Template KNART Validation Report
Associated Resource
Age-Related Eye Disease Study (AREDS) AMD Category definitions in Age-Related Macular Degeneration Preferred Practice Patterns
Associated Resource
ICD-10 Glaucoma Staging Definitions
Associated Resource
American Academy of Ophthalmology EyeWiki Gonioscopy Classification
References

See attached resource files for additional details. Department of Veterans Affairs, Veterans Health Administration, Office of Informatics and Information Governance, Clinical Decision Support (CDS) Content and Health Level 7 (HL7)-Compliant Knowledge Artifacts (KNARTs) Eye Care Clinical Content White Paper, VA118-16-D-1008, Task Order VA-118-16-F-1008-0007, June, 2018.

American Academy of Ophthalmology Preferred Practice Pattern Cataract/Anterior Segment Panel. Preferred Practice Pattern Guidelines. Cataract in the Adult Eye. American Academy of Ophthalmology Preferred Practice Pattern Guidelines website. Updated October 2016
https://www.aao.org/preferred-practice-pattern/cataract-in-adult-eye-ppp-2016
American Academy of Ophthalmology Preferred Practice Pattern Committee. Preferred Practice Pattern Guidelines. Comprehensive Adult Medical Eye Evaluation. American Academy of Ophthalmology Preferred Practice Pattern Guidelines website. Updated November 2015
https://www.aao.org/preferred-practice-pattern/comprehensive-adult-medical-eye-evaluation-2015
American Academy of Ophthalmology Preferred Practice Pattern Glaucoma Panel. Preferred Practice Pattern Guidelines. Primary Open-Angle Glaucoma. American Academy of Ophthalmology Preferred Practice Pattern Guidelines website. Updated November 2015
https://www.aao.org/preferred-practice-pattern/primary-open-angle-glaucoma-ppp-2015
American Academy of Ophthalmology Preferred Practice Pattern Glaucoma Panel. Preferred Practice Pattern Guidelines. Primary Open-Angle Glaucoma Suspect. American Academy of Ophthalmology Preferred Practice Pattern Guidelines website. Updated January 2015
https://www.aao.org/preferred-practice-pattern/primary-open-angle-glaucoma-suspect-ppp-2015
American Academy of Ophthalmology Retina/Vitreous Panel. Preferred Practice Pattern Guidelines. Diabetic Retinopathy. American Academy of Ophthalmology Preferred Practice Pattern Guidelines website. Updated December 2017.
https://www.aao.org/preferred-practice-pattern/diabetic-retinopathy-ppp-updated-2017
Bailey IL. Visual acuity. In: Benjamin WJ, ed. Borish\u2019s clinical refraction. 2nd edition. St. Louis, MO: Butterworth-Heinemann, 2006
https://www.elsevier.com/books/borishs-clinical-refraction/benjamin/978-0-7506-7524-6
Digital Imaging and Communications in Medicine. DICOM Standards Committee. RR.2 Reference Tables For Equivalent Visual Acuity Notations. DICOM PS3.17 2017e webpage. Updated November 2017.
http://dicom.nema.org/medical/dicom/current/output/pdf/part17.pdf
Eleu Pacific Partners. Reusable Data Elements: Research Initiative for Optimal Vision Care Prototype Deliverable 10. Updated March 2015.
 
Eleu Pacific Partners. Storyboards and Mockups: Research Initiative for Optimal Vision Care Prototype Deliverable 3. Updated July 2015.
 
Eye Care SMARTForm. Eye Care Wireframes 031915.pdf. March 19, 2015. (Veterans Administration, provided documentation from Linda Wedemeyer, MD, U.S. Veterans Administration).
 
Holladay JT, Visual acuity measurements. J Cataract Refract Surg. 2004;30(2):287-290
https://doi.org/10.1016/j.jcrs.2004.01.014
U.S. Department of Veterans Affairs VA Clinical Capabilities Management Board. Program name: Integrated electronic health record and registry for eye care. January 17, 2017. Business Owner Presentation Integrated Electronic Health Record Eye Care_FY19-23 IT MYP CCMB.PPTX (U.S. Department of Veterans Affairs, provided documentation from Mary Lynch, MD, U.S. Department of Veterans Affairs).
 
U.S. Department of Veterans Affairs. VA FORM 10-150058(WS) \u2013 class III NSR initial assessment questionnaire: Medflow EHR for Eye Care NSR.PDF (U.S. Department of Veterans Affairs, provided documentation from Mary Lynch, MD, U.S. Department of Veterans Affairs).
 
Medflow/DSS electronic health record for eye care in the VA. Poster presented at: Healthcare Information and Management Systems Society (HIMSS) 2012 Annual Meeting; February 20-24, 2012; Las Vegas, NV. HIMSS Poster Medflow Feb 2012.pdf. Lynch MG, Varga J, Skarda D, Maa A, 2012.
 
U.S. Department of Veterans Affairs. Optimal Vision Care Prototype (OVCP) Functional Requirements. Updated April 2015.
Artifact Representation
Testing Experience
Pilot Experience
None