Determining the Minimum Data Set of Amblyopia Electronic Health Record

To collect, store, and distribute the electronic health records of patients with amblyopia, it is important to determine the data elements. The present study aims to determine the minimum data set (MDS) for electronic health record of patients with amblyopia in Iran.

This is an applied study that was conducted in 2020. To identify data elements, a search was conducted in PubMed, Scopus, Google Scholar, Web of Science, Scientific Information Database (SID), Magiran and Barakat knowledge system and the records of patients with amblyopia were examined and consultation with ophthalmologists in Farabi Hospital was done. Then, a questionnaire with two sections of “demographic information” and “suggested MDS for amblyopia” was prepared based on a five-point Likert scale. After confirming the validity and reliability of the questionnaire, it was completed by 20 experts from the amblyopia clinic of Farabi Hospital who were selected using a convenience sampling method. Data analysis was done using descriptive statistics in SPSS software. The data elements with an agreement score >3 were selected for the MDS of amblyopia.

Out of 98 proposed data elements, 92 were included in the MDS for amblyopia and were classified into 6 categories of demographic data, clinical data, type of strabismus, sensory tests, doctors’ prescriptions, and treatment plan.

It seems that the integration of information for patients with amblyopia in Iran and the improvement of their information management can be possible by determining the MDS for their electronic health record. By storing and retrieving standard electronic health information based on a minimum data set, it is possible to compare information, obtain high-quality information, and increase the effectiveness of medical services.