General Eye Evaluation
The General Eye Evaluation content profile defines the structure of the data that is often collected during a patient’s general eye examination. The American Academy of Ophthalmology (AAO) has created a collection of recommended best practices for this and other aspects of eye care that it terms the Preferred Practice Patterns (PPP). The information in this document is based upon the “Comprehensive Adult Medical Eye Evaluation October 2010” PPP specification generated by the AAO. The comprehensive eye examination consists of an evaluation of the physiological function and the anatomical status of the eye, visual system and its related structures.
The defined content is a super-set of the HL7 Consolidated CDA as adopted by MU2.
The benefits include providing a common means of exchanging the data contained in the routine eye exam among providers and settings in an encoded format, leveraging use of international terminology standards, and providing access to commonly reported data to avoid duplications and errors.
Comprehensive eye care deals with a broad spectrum of specialty disciplines each with its own lexicon, examination techniques, and procedures. The highest volume and most central component of this is the routine adult eye examination. A patient presents for a general eye examination and demographic data is either created, retrieved from existing databases, or updated. The patient provides a chief complaint and historical information relevant to the eye, and a partial or complete examination of the eye and visual system is performed using various optical devices. Multiple people may contribute to this process including receptionist, technician, and physician.
The PPP for a Comprehensive Adult Medical Eye Evaluation provides a roadmap for data collection. The nature of the data varies widely and may be discrete and defined by existing terminology standards (e.g., visual acuity, intra ocular pressure) or narrative and available only as free text (e.g., description of a lesion, description of morphology). After this data is collected the clinician will arrive at an assessment and management plan. All of this must be recorded in a fashion that will allow subsequent transfer across diverse information platforms without loss of content or meaning using existing standards and protocols.
- Electronic Medical Record System or Departmental information systems that manage department scheduling)
Actors & Transactions:
There are two actors in this profile, the Content Creator and the Content Consumer. Content is created by a Content Creator and is consumed by a Content Consumer. The sharing or transmission of content from one actor to the other is addressed by the appropriate use of IHE profiles described below, and is out of scope of this profile. A Document Source or a Portable Media Creator may embody the Content Creator Actor. A Document Consumer, a Document Recipient or a Portable Media Importer may embody the Content Consumer Actor. The sharing or transmission of content or updates from one actor to the other is addressed by the use of appropriate IHE profiles described in the section on Content Bindings with XDS, XDM and XDR in PCC TF-2:4.1
Profile Status: Trial Implementation Version