The Importance of Patients' Clinical Information

Providing critical patient information along with the images you upload to the picture archiving system can make a big difference in the value of the report your consultant can provide you. Let’s look at the intake form you are provided to illustrate the subtleties between necessary information and helpful information.

The patient demographics section has some items in red – those are critical. Be sure to use a medical record number related to your own clinic. The provider name is important, as is ethnicity/race. Why the latter? Because some ethnicities are more susceptible to certain eye diseases. Of course, if the patient chooses not to identify this, you can leave it blank.

Basic patient information (name, birth date, gender, etc.) can be written on paper and photographed before you start imaging the eyes. This will help identify the patient whose images are being captured and recorded. However, DO NOT UPLOAD such patient information. Sent in that format, the information cannot be encrypted, and you are risking a HIPAA violation. It is a good idea for you to record the retinal images immediately following an image of patient information, but that is FOR YOUR RECORDS ONLY. It might be helpful in the future, but it’s not meant for uploading.

Insurance Coverage Type is important to your consultant. It can signal what type of follow-up options might be available to this patient. It’s not necessary, but it is helpful information. And do feel free to ask EyePACS for help in customizing this information box if you wish to list specific payers important to your own clinic.

In the grand scheme of things, Clinical History is very important. Items in red are absolutely necessary. Some items can simply be asked of the patient: years with diabetes, last eye exam, medications, and history, such as pregnancy. It is very helpful to know the date of the last A1C blood draw but, if you don’t have the date, do be sure to include the A1C level anyway. Blood pressure is very helpful to us too in relation to the images and other data. Within the clinical history section, four items are vital: Years with diabetes; date of last eye exam; medications; and “other history information.”              

Date of last eye exam is also critical, but that sometimes means something very different to the patient than to the consultant. For example, an acuity test at the DMV is not, to us, an eye exam. We are not referring, either, to a DR screening such as the type they are about to undergo, nor are we referring to a low-cost, non-dilated live exam, such as at a drug store. What actually constitutes the “last eye exam” is a comprehensive examination that included pupillary dilation. Sometimes the information a patient reports to you introduces inexplicable discrepancies. For example, “I have had cataract surgery… No, I’ve never had an eye exam.” Or “I have a history of high pressure in both eyes… No, I’ve never had an eye exam.” In cases such as these, the disconnect presents difficulties to the consultant. However, it is better to include all the historical exam information you can, even if it does not make complete sense to you. If you can gently probe for a better explanation, you might be able to connect the dots.

Many of the patients you will be screening are on a lot of medication; writing the list is time-consuming and sometimes not even possible. Feel free to use logical abbreviations where possible. For example, hydrochlorothiazide can be abbreviated HCTZ, and aspirin can be written as ASA. If you cannot get a complete list of medications, at least make note of the medical conditions for which the patient is taking medication. Be sure to include any unusual medications being taken, such as Plaquenil or Interferon. In most cases it is not necessary to detail the amount or frequency of dosing unless it’s an unusual medication.

Other history or information is really helpful if conveyed appropriately. When you are reporting an unusual situation or unusual symptoms, include all the facts you possibly can. For example, if a patient reports he is blind in the left eye, has that been from birth? In the past year? Suddenly for no apparent reason or due to trauma? These are some of the conditions that are really important to report:

·      Sudden and profound vision loss, or sudden vision loss in one eye

·      Significant eye pain or redness, especially in one eye (not irritation, but pain)

·      Anything YOU think might be pertinent to the case

Ask patients for more information through these questions:

·      How often?

·      How long?

·      Constant problem or episodic?

·      Getting worse? Getting better? Staying about the same?

And don’t be disappointed if the consultant does not refer to these notes in his or her report. The consultant might simply decide, based on the images and the information you have provided, that this is not an indication of serious pathology. Notice that, once you’ve uploaded the case, you have the option, with the click of a mouse, to request an urgent email consult.

To view this original presentation by Dr. Harry Green. OD, PhD, visit our Learning Community, February 2013.