CATARACT EWAP MARCH 2024 15 documentation error.” Coming from a paper chart perspective, Dr. Zhu said the most common error she sees is the wrong information in the wrong chart. “I think it still applies even for clinics that are all digital because there are some things that are not completely connected to your EHR. There are a lot of scans that you have to print out and scan into the EHR. That can be uploaded into the wrong patient record. That’s the most common error that I’ve seen,” she said. “Sometimes it’s a completely different patient, and sometimes it’s because the patient shares the same name, so you always have to verify the birthday as well.” Dr. Zhu said this has happened in her practice when technicians are printing out from devices one after another, and sometimes the whole stack of papers is scooped up and put into a chart. Sometimes, sandwiched in the middle are scans from another patient. “I’ve educated my staff to not blindly scoop up the whole stack from the printer. They should individually look through each paper as they’re putting it into the chart, verifying the name and birthday,” she said. Dr. Zhu and Dr. Bartlett have not experienced a negative patient outcome due to a chart error personally, though they have caught errors through safety checks before they could affect outcomes and have heard of such situations from other practices. Dr. Bartlett said that human errors can be counteracted before and during surgery with systems of safety, including multiple checks by multiple people. “I work with an optometrist. When we see patients, we generate our lens orders, so when we do our calculations and pick a lens for the patient, he and I do that separately, and we compare the results. If there is any discrepancy, we figure out why there is a difference so it’s very clear what they elected for and what we are selecting. Once you type it in the EHR, it looks like that’s the reality. Unless you have some other check on it, you could easily make an error,” Dr. Bartlett said. Dr. Zhu said with ICLs, she makes sure to triple check that she’s ordering a lens with the correct axis because in the clinic, minus is used for cylinder during refractions, but the ICL needs to be converted to plus. She checks the ICL power when it is delivered to her practice before the patient is even scheduled and again on the day of surgery. It is very easy to mistakenly flip the plus/ minus sign on the astigmatism, and the patient could end up with double the amount of astigmatism they started with. Editors’ note: Dr. Fram practices at Advanced Vision Care, Los Angeles, California. Dr. Kim is in private practice with Professional Eye Associates, Dalton, Georgia. Neither disclosed relevant financial interests. Pro for paper Dr. Zhu said she likes having everything in one place and being able to spend more time “face time” with the patient rather than on a computer. “I can review a chart and see the OCT, topography, biometry simultaneously. It’s also easy for me to handwrite notes in the chart to do calculations or highlight important findings when making my final IOL selection. It’s a little cumbersome when everything is electronic and you have to open different windows to do those same evaluations,” she said. Pro for digital While EHRs are, to some degree, “universally hated” among ophthalmologists, Dr. Bartlett said, enhanced communications facilitated by the electronic record is a plus. “There have been times in the past when I’ve gotten paper records and I can’t make out anything on it, so it’s zero information,” he said. “I think there is a value in being able to better communicate among physicians, to communicate with patients, and that leads to better patient care.” The same holds true for LASIK. It is important to verify that the refraction that is programmed into the laser matches the final refraction obtained on surgery day. “As a safeguard, I double check to make sure that the final refraction written in the chart is consistent with a recent refraction that was obtained at a separate preoperative visit. I then confirm once more that the numbers in the machine match the numbers in the chart with my laser surgical technician just before hitting the pedal,” she said. While these safeguards and surgical timeouts are not built into the EHR, Dr. Bartlett said EHRs do have some safety measures. For example, if a patient has listed an allergy and a doctor tries to order a medication they’re allergic to, the system would flag it. It also flags dosages that might be considered unsafe. From a business standpoint, medical documentation errors can be costly, not only in terms of OR resources, if a patient needs to be brought in for an additional procedure, but also in terms of insurance denials and the staff time needed to correct these issues and resubmit. Mr. Christensen gave an example. He said the Moran Eye Center recently underwent a “Target, Probe, and Educate” audit for cataract surgery. The findings included documentation omissions: “Per LCD L37027, documentation must include an attestation supported by documented symptoms and continued on page 20
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