Electronic Medical Records standards for UK ophthalmology services

  • 12 Feb 2024
  • Informatics and Audit Sub-committee

Electronic medical records (EMRs) have a big impact on how a clinical service is delivered as well as facilitating audit, research and clinical governance . This guidance explores the components integral a good EMR to support eye care and is particularly relevant to those organisations making procurement decisions.

To provide the best care for patients, and to generate improvements in care, it is important to be able to measure the quality of clinical and supporting services provided and ensure minimum quality standards are met. EMRs are increasingly helping clinical teams achieve this by recording clinical care in a legible and standardised manner to measure the quality of the services they provide (e.g. through more automated clinical audit). However, while EMRs have many potential benefits, their use is not without well-documented risks.

  1. Standards: which specifically address, or are considered particularly pertinent to, ophthalmic care. They do not attempt to cover generic ground which has been comprehensively described or laid out in separate standards elsewhere.2 Instead they aim to focus on a small number of key areas and standards which are important for the delivery of high-quality ophthalmic care. It is not expected most EMR vendors will comply with all the standards set out in this document, but the minimum standards are indicated by a “must”.
  2. Datasets: Datasets are being developed by the RCOphth for each of the ophthalmic sub-specialities. These datasets are designed to serve the breadth of eyecare, have gateway disease modules and contain components common across ophthalmic sub-specialities. It is anticipated the contents of these datasets are adopted by an EMR provider.
  3. Ophthalmic specific and Hospital Information Systems: The document considers some of the pros and cons of an ophthalmic specific EMR compared to the use of a general electronic patient record the organisation uses for other specialties. These considerations should be useful when ensuring procurement decisions provide the greatest benefit for ophthalmic services and patients.