Abstract
BACKGROUND: Ophthalmologists' letters and medical reports play an important role in the interdisciplinary cooperation between general practitioner, internist, diabetologist and ophthalmologist providing means of information and communication for the avoidance, delay and treatment of diabetic retinopathy (DR). METHODS: In a cross-sectional study (NCT02311504) the ophthalmologicsts' letters and other clinical parameters were extracted from electronic patient records (EPR) of 810 patients with diabetes. Files were classified into different categories of formats, tested with respect to topicality and content structure and analyzed according to the topic complex of the national treatment guidelines for retinal complications. RESULTS: In 59% of the patients an ophthalmologist's medical report was identified in the EPR. Of these, 26% were computer-generated documents, 73% were handwritten. 55% used the standard form of the national guidelines, 21% were self-designed formats, 16% detailed letters, 5% short reports and 3% short messages. The information was written on average 19 months ago. Of the documents 25% were older than 2 years at the time of the study. Of the patients 75% visited an ophthalmologist in the previous 12 months, yielding a report rate of only 40%. The prevalence of DR reported in the forms was 12%, in detailed letters 32%. CONCLUSION: Although standardized forms are widely distributed in the ophthalmologists' communication with diabetologists, there is room for improvement in the face of the low report rate to enable a timely consideration of relevant findings. The high number of handwritten documents shows the large untapped potential of electronic formats in the interdisciplinary communication.