J Med Syst (2010) 34:883–889

DOI 10.1007/s10916-009-9303-8

ORIGINAL PAPER

Outpatients Flow Management and Ophthalmic Electronic

Medical Records System in University Hospital Using Yahgee
Document View
Toshihiko Matsuo & Akira Gochi & Tsuyoshi Hirakawa &
Tadashi Ito & Yoshihisa Kohno

Received: 1 February 2009 / Accepted: 16 April 2009 / Published online: 15 May 2009
# Springer Science + Business Media, LLC 2009

Abstract General electronic medical records systems re- systems for documents and images by Yahgee Document
main insufficient for ophthalmology outpatient clinics from View (Yahgee, Inc.) were introduced on the platform of
the viewpoint of dealing with many ophthalmic examina- general electronic medical records system (Fujitsu, Inc.).
tions and images in a large number of patients. Filing Outpatients flow management system and electronic med-
ical records system for ophthalmology were constructed.
All images from ophthalmic appliances were transported to
Financial Disclosure(s) Toshihiko Matsuo and Akira Gochi in Yahgee Image by the MaxFile gateway system (P4 Medic,
Okayama University have no proprietary or commercial interest in any
materials discussed in this article. Inc.). The flow of outpatients going through examinations
such as visual acuity testing were monitored by the list
T. Matsuo (*)
“Ophthalmology Outpatients List” by Yahgee Workflow in
Department of Ophthalmology,
Okayama University Medical School, addition to the list “Patients Reception List” by Fujitsu.
2-5-1 Shikata-cho, Patients’ identification number was scanned with bar code
Okayama City 700-8558, Japan readers attached to ophthalmic appliances. Dual monitors
e-mail: matsuot@cc.okayama-u.ac.jp
were placed in doctors’ rooms to show Fujitsu Medical
T. Matsuo Records on the left-hand monitor and ophthalmic charts of
Graduate School of Medicine, Dentistry, and Pharmaceutical Yahgee Document on the right-hand monitor. The data of
Sciences, Okayama University, manually-inputted visual acuity, automatically-exported
2-5-1 Shikata-cho,
autorefractometry and non-contact tonometry on a new
Okayama City 700-8558, Japan
template, MaxFile ED, were again automatically trans-
T. Matsuo ported to designated boxes on ophthalmic charts of Yahgee
Department of Ophthalmology, Document. Images such as fundus photographs, fluorescein
Okayama University Hospital,
angiograms, optical coherence tomographic and ultrasound
Okayama City, Japan
scans were viewed by Yahgee Image, and were copy-and-
A. Gochi pasted to assigned boxes on the ophthalmic charts.
Department of Medical Informatics, Ordering such as appointments, drug prescription, fees
Okayama University Hospital,
and diagnoses input, central laboratory tests, surgical
Okayama City, Japan
theater and ward room reservations were placed by
T. Hirakawa functions of the Fujitsu electronic medical records system.
Yahgee Inc., The combination of the Fujitsu electronic medical records
Tokyo, Japan
and Yahgee Document View systems enabled the University
T. Ito Hospital to examine the same number of outpatients as prior
P4 Medic, Inc., to the implementation of the computerized filing system.
Osaka, Japan
Keywords Electronic medical records . Ophthalmology .
Y. Kohno
Fujitsu Chugoku Systems, Ltd., Images . Patient flow . Ophthalmic examination .
Hiroshima City, Japan Ophthalmic appliances
884
The ophthalmology department is unique in both General
Hospitals and University Hospitals. This is due to (1)
ophthalmology has many intradepartmental examinations
such as visual acuity test, refraction, and visual field test,
(2) ophthalmology has to conduct these examinations in the
department and does not outsource the examinations to
central laboratories in the hospital, (3) outpatients’ flows in
the department become complicated due to many examina-
tions, (4) ophthalmology department deals with a large
number of images by fluorescein angiography, ultrasonog-
raphy, and optical coherence tomography, and (5) the
number of patients in outpatients clinics for ophthalmology
is usually large.
These situations are in marked contrast with the other
departments in a general hospital. For instance, in internal
medicine, all examinations including X-rays, blood tests,
electrocardiography, and endoscopy are sent out to central
laboratories of the hospital. Electronic medical records
systems are usually introduced first as ordering systems to
place an order or make a reservation for each examination
at the central laboratories and to view the result images and
reports. The ordering system also comprises appointments
for doctors, prescriptions for pharmacy, charges for fees,
and input of diagnoses. Later, in addition to the ordering
system, electronic medical charts adhering to the format of
the SOAP system (subjective, objective, assessment, and
plan) have been included to complete the electronic medical
records system [1].
To make electronic medical records systems function
properly for ophthalmology, the unique points described
above have to be solved, and additional systems have to be
included in the present electronic system for a general
hospital. Under the circumstances, we made two predis-
positions toward the development of electronic medical
records systems for ophthalmology: (1) ophthalmology as a
department should not be considered unique in a hospital,
and (2) ophthalmology department should share electronic
medical records systems with all the other departments in the
hospital. In this study, we constructed both outpatients’ flow
management system and electronic medical records system
for ophthalmology, using Yahgee Document View system on
the platform of the electronic medical records systems for
general hospitals.
Methods
A new server (Yahgee Document View, Yahgee, Tokyo,
Japan) for filing documents and images was introduced on
the platform of a general electronic medical records system
(HOPE/EGMAIN-EX, V04 up to December 2008, and
HOPE/EGMAIN-GX from January 2009, Fujitsu, Tokyo,
Japan) in Okayama University Hospital. In order to
J Med Syst (2010) 34:883–889
accurately integrate the Fujitsu electronic medical records
system and the Yahgee system, the majority of information
such as basic patients’ attributes was sent to the Yahgee
system upon real time registration in the Fujitsu system
which was the main system. Conversely, upon the docu-
ment creation in the Yahgee system, parts of the contents
were sent in real time to the Fujitsu electronic medical
records system from the Yahgee system. This tie-up was
accomplished by an interface application acting between
both servers and utilized the communication specification
with transmission control protocol/internet protocol (TCP/
IP). The received information at each server could be
referred by the client application on each side. At each
terminal in every section of the hospital, Yahgee application
was started from a unique button on the menu of the Fujitsu
electronic medical records system. Thus, both systems
could be used like a single system.
Ophthalmic appliances were connected to Yahgee
Document View by a gateway of the software, MaxFile
(P4 Medic, Osaka, Japan). Images from ophthalmic
appliances were exported and inputted into the MaxFile
and then transported automatically to Yahgee Image.
Numerical data of visual acuity testing (uncorrected and
best-corrected visual acuity with spherical lens diopters
and cylindrical lens diopters and axis) were inputted
manually on a new template developed as MaxFile ED
on the basis of MaxFile while the data of autorefracto-
keratometry and non-contact tonometry were automati-
cally exported to this new template. The Ophthalmology
Outpatients List was made by Yahgee Workflow
(Yahgee) to place a check mark automatically on the
list when each patient finishes each examination with
reservations.
Regarding the integrated filing of examination results,
Yaghee Image was also connected to radiographic image
systems such as computed tomography and magnetic
resonance imaging in picture archiving and communication
systems (PACS). In addition, endoscopic, ultrasonographic,
and pathological images in other medical sections, includ-
ing internal medicine, gynecology, otolaryngology, and
dentistry, were also retrieved and used for document
creation to make reports by Yahgee Document; extensible
markup language (XML) format was used in this process as
the medium of transferring information.
Yahgee Document had templates for document creation
to make reports for medical examinations, which provided
boxes to paste radiographic, endoscopic, ultrasonographic,
pathological, and any other images. In addition, the
templates were used as documents, for example, by the
nutritional support team and discharge support team, and
were shared by all the staffs in the hospital including
doctors, nurses, and other healthcare professionals. Oph-
thalmology was the only medical section to use Yahgee
J Med Syst (2010) 34:883–889 885

Document to create medical charts which retrieved auto-
matically the data of visual acuity testing, autorefractokera-
tometry, and non-contact tonometry.
Results
Outline of ophthalmology department outpatients clinic
Ophthalmology Department in Okayama University Hospi-
tal had six doctors’ rooms, and six doctors, in parallel,
examined patients in each room. In addition, the Depart-
ment had a visual acuity-testing room, strabismus-testing
room, visual field-testing room, electroretinography room,
laser treatment room, photography room, and treatment
room. One or two clerks worked at the reception room for
the entire Ophthalmology Department, four nurses covered
all the doctors’ and examinations rooms, and six orthoptists
worked: two for strabismological examinations and four for
visual acuity, autorefraction, non-contact tonometry, visual
field, and optical coherence tomography. One or two
doctors took fluorescein and indocyanine green angiogra-
phy in the photography room and one doctor worked in the
treatment room.
The number of new patients and revisiting patients was
103 and 2,396 in the 1-month of October 2008. Two days
(Tuesday and Thursday) a week were for new and revisiting
patients, 1 day (Wednesday) for revisiting patients to
subspecialty clinics, and 2 days (Monday and Friday)
basically for surgery and only for revisiting patients with
reservations for examinations such as visual field tests,
specular microscopy and axial length measurements.
Emergency patients were seen on request. The mean
number of new patients per day was 13 when 103 patients
were divided by 8 days (2 days in a week times 4 weeks),
and the mean number of revisiting patients per day was 200
when 2,396 patients were divided by 12 days (3 days in a
week times 4 weeks).
Referral letters from outside clinics and hospitals were
scanned by clerks later at the Medical Informatics Depart-
ment. As described below, the Ophthalmology Department
had three scanners: one was placed in the strabismus-testing
room for scanning the strabismological examination sheet
immediately by orthoptists, and the second placed in the
visual acuity-testing room for scanning Goldmann perime-
try and color vision testing, and the third placed in the ward
examination room.
Ophthalmology outpatients flow
New and revisiting patients registered at the reception
counters on the ground floor of the Outpatients Building,
and a hospital navigation card (Fig. 1) in the A4 size for
each patient was printed out to show appointments for
doctors and reservations for examinations. Revisiting
patients could also register at automatic reception machines.
When patients arrived at the reception room in the
Ophthalmology Department on the forth floor, an ophthal-

Fig. 1 Hospital navigation card

(left) and ophthalmic navigation
card (right). A barcode to indi-
cate patient’s identification
number is printed on each card
and used for input to ophthalmic
appliances and for opening of
medical records. Patients keep
the hospital navigation cards
while staffs keep the ophthalmic
navigation cards. The ophthal-
mic navigation cards have diag-
noses and preceding visual
acuity-testing results for staffs’
reference. An additional order or
notice to staffs can be hand-
written on the ophthalmic navi-
gation cards
886
mic navigation card (Fig. 1) in the A4 size was printed out.
The ophthalmic navigation cards for patients with appoint-
ments and reservations were printed out beforehand, sorted
and placed at each of doctors’ rooms and examinations
rooms in the sequence of the appointment and reservation
time. The cards for patients with pre-doctor examinations
(visual acuity, autorefraction, non-contact tonometry, and
optical coherence tomography) were placed in the visual
acuity-testing room, the cards for patients with no pre-
doctor examination were placed in each doctors’ room, the
cards for patients with strabismological examinations were
placed in the strabismus-testing room, the cards for patients
with fluorescein and indocyanine green angiography were
placed in the photography room. Patients kept the hospital
navigation cards until charge settlement while ophthalmol-
ogy staffs kept the ophthalmic navigation cards.
Process of ophthalmic examinations
In the visual acuity-testing room, patient’s identification
number printed on the ophthalmic navigation card was
scanned by a barcode reader attached to ophthalmic
appliances for autorefractokeratometry and non-contact
Fig. 2 Process of ophthalmic practice. Patient’s identification number
printed on the navigation card is inputted into autorefractokeratometry
appliance by a barcode reader, and autorefraction is measured and
exported to the MaxFile ED template (top right). Numerical results of
visual acuity tests are manually inputted into the MaxFile ED template
using a Ten Key number pad (top left). Images of optical coherence
tomography are exported and inputted into MaxFile (bottom left). In a
J Med Syst (2010) 34:883–889
tonometry, and the data were exported and inputted into
the MaxFile ED template (Fig. 2). Numerals of visual
acuity tests were manually inputted into the MaxFile ED
template (Fig. 2). All the data on the MaxFile ED template
were retrieved by MaxFile ED Web Viewer by clicking the
Ophthalmic Tests Result Link, placed next to ophthalmic
charts of Yahgee Document.
In a doctor’s room, patient’s identification number
printed on the ophthalmic navigation card was scanned by
a barcode reader to select the patient in the Ophthalmology
Outpatients List of Yahgee Workflow (Table 1), and an
ophthalmic chart was opened as one of four template types
(free, new patient, revisiting patient, and ward template). In
parallel, the patient was selected from the Patients Recep-
tion List on the Fujitsu electronic medical records system to
open the medical record. When any type of ophthalmic
charts was opened, the numerical data of visual acuity,
autorefractokeratometry, and non-contact tonometry on
MaxFile ED Web Viewer were automatically transported to
designated boxes of the ophthalmic chart, as reference to the
same date. Dual monitors were placed in doctors’ rooms to
show the Fujitsu medical records on the left-hand monitor
and the Yahgee ophthalmic chart on the right-hand monitor.
doctor’s room, slit-lamp biomicroscopic images are captured by a
CCD camera and directly inputted into MaxFile (bottom right). The
data in the MaxFile ED template are retrieved by MaxFile ED Web
Viewer from Ophthalmic Tests Result Link and automatically trans-
ported to the ophthalmic chart on the same date of Yahgee Document.
The images in MaxFile are automatically transported to Yahgee Image
J Med Syst (2010) 34:883–889 887

Table 1 Summary of the Yah-

gee Document View system
Yahgee Document automatically shown in page-turning view
Yahgee Image
Yahgee Workflow for reimbursement notice (for doctors)
Ophthalmology Outpatients List
Departmental Videocapture (slit-lamp biomicroscopy)
Departmental File/Scan Image Upload (Goldmann perimetry, color vision tests,
Hess red-green test, strabismological tests)
Yahgee Document Reference Tools
Departmental Videocapture for slit-lamp biomicroscopy
Ophthalmic Tests Result Link
Access to MaxFile ED Web Viewer by a gateway of MaxFile ED template (P4 Medic)
Humphrey Visual Field Link by a gateway of HfaFiles (Beeline)
Yahgee Document Icon
Yahgee Image Icon
Yahgee Documents templates
Uniform letters for diagnosis and notification
Uniform letters for referral
Ophthalmology medical records
Ophthalmic chart (free)
Ophthalmic chart (revisiting patient)
Ophthalmic chart (new patient)
Ophthalmic chart (ward)
Ophthalmology surgical records
Ophthalmology other documents
Glasses prescription
Contact lenses prescription
Reimbursement for glasses and contact lenses for amblyopia treatment
Intraocular lens order

Hand-written strabismological examination sheets in the
A4 size, Goldmann perimetric sheets (one for the right eye and
the other for the left eye) in the A4 size, Hess red-green test
(Hess chart) and color vision test sheets were scanned and
uploaded to Yahgee Image (Table 2). Images of fundus
camera, optical coherence tomography, specular microscopy,
and ultrasonography were exported and inputted into the
MaxFile frameworks, and then automatically transported to
Yahgee Image (Fig. 2). Humphrey visual field-testing results
were viewed via the software, HfaFiles Ver.5 (Beeline, Inc.,
Machida, Japan) by clicking on Humphrey Visual Field Link,
placed next to the ophthalmic chart of Yahgee Document.
The results for A-mode ultrasound axial length measurement
and calculation for intraocular lens powers were printed out,
pasted on an A4 sheet, scanned and uploaded to Yahgee
Image since electronic output of numerical data from the A-
mode axial length-measuring appliances was incomplete.
Slit-lamp biomicroscopic images were captured through a
CCD camera (Fig. 2) and inputted into the MaxFile frame-
works, and then automatically transported to Yahgee Image.
Drawings such as retinal detachment charts were later
scanned and uploaded to Yahgee Image.
Images in Yahgee Image could be sent to assigned boxes
of the ophthalmic charts of Yahgee Document by clicking
“Send to Reports”. The images were also printed out to
hand them to patients and for enveloping them together
with answer letters to referrals. On the ophthalmic charts,
pictures were drawn on templates for ocular fundus,
anterior segments, and iridocorneal angles.
Fujitsu medical records systems
Next appointments, reservations for ophthalmic examina-
tions, prescription for drugs, fees input, and diagnoses input
were processed in the Fujitsu electronic medical records
systems (Table 3). The orders and reservations to central
laboratories such as radiography and blood tests, as well as
surgical theater and ward room reservations, were also
placed. The Fujitsu system was first closed, and then,
prescription notice, appointments and reservations cards
were printed out. The ophthalmic charts of Yahgee
Document could be kept open and be closed later for
additional writing. This late saving to the sub-server,
independent of the main systems, was made possible only
888
Table 2 Summary of data capture for ophthalmic examinations
MaxFile ED: retrieved by MaxFile ED Web Viewer and automatically
transported to the ophthalmic chart of Yahgee Document
Visual acuity: manual input of numerals into MaxFile ED template
Non-contact tonometry: automatic export of data to MaxFile ED
template
Autorefractokeratometry: automatic export of data to MaxFile ED
template
Export and input into MaxFile: automatically transported to Yahgee
Image
Fundus camera for funduscopy, fluorescein and indocyanine green
angiography (one in outpatients clinic and another in ward)
Scanning laser ophthalmoscopy digital versatile disk (DVD)
recording
Optical coherence tomography
Specular microscopy for corneal endothelial cells
B-mode ultrasonography, ultrasound biomicroscopy for anterior
segments (one in outpatients clinic and another in ward)
Videocapture and input into MaxFile: automatically transported to
Yahgee Image
Slit-lamp biomicroscopy (six in outpatients clinic and two in ward)
Hand-held fundus camera
Scan and image capture: uploaded and transported to Yahgee Image
Strabismological tests
Hess red-green test (Hess chart)
Goldmann perimetry
A-mode ultrasound axial length measurement
Calculation for intraocular lens power
Color vision tests (Panel D15, Ishihara color plates)
Electroretinography
Drawings such as retinal detachment charts
Humphrey field analyzer: accessed from Humphrey Visual Field
Link by a gateway of HfaFiles (Beeline)
when Yahgee Document was opened from the Ophthalmol-
ogy Outpatients List.
Discussion
The electronic medical records system is still in the process
of development and has to be revised and updated to keep
abreast with advances in hardware and software technology.
Most hospitals have introduced electronic ordering systems
and electronic medical records systems, and under the
circumstances, the ophthalmology department as one
section of a general hospital has to be involved in the
entire systems of the hospital. However, the recent standard
of the electronic medical records system still remains
insufficient to practice ophthalmology in the convenience
because of the unique points inert to ophthalmology as
mentioned in the Introduction.
J Med Syst (2010) 34:883–889
Some companies provide electronic medical records
systems specifically designed for ophthalmology, which
function well in single practice of ophthalmology. Some
general hospitals have introduced such ophthalmic elec-
tronic medical records systems on the platform of the
general electronic medical records systems. The problems
which have to be solved in this approach are: (1) the
linkage between the ophthalmic system and the general
system is sometimes difficult, (2) the sorting of functions
(fees input, diagnoses input, and reservations for examina-
tions) between the ophthalmic and general systems is
difficult to decide from the viewpoint of coordinating with
the other departments in the hospital, (3) the hospital
administration does not understand why only the ophthal-
mology department requires a specifically designed medical
records system with a high cost in addition to the general
Table 3 Ordering through Fujitsu electronic medical records system
Open from the Fujitsu medical records system
Appointments and reservations
Doctors (room numbers)
Visual acuity-testing room (visual acuity, non-contact tonometry,
autorefractokeratometry, mydriasis, optical coherence tomography)
Strabismus-testing room (strabismological examinations)
Visual field tests (Humphrey and Goldmann visual fields)
Fundus camera and angiography (fluorescein and indocyanine
green angiography)
Preoperative examinations (specular microscopy, axial length
measurement, intraocular lens power calculation)
Prescription ordering
Injection ordering
Diagnoses input
Fees input
Documents
Informed consent forms for lasers, surgeries, and angiography
Templates
In-hospital referral letter
Surgical theater reservation
Ward room reservation
radiographic ordering
blood tests ordering
Culture tests ordering
Physiological tests ordering
Electrocardiography
Lung volume test
Pathology diagnosis ordering
Close the Fujitsu medical records system
→print out of appointments, reservations, and drug prescription
Keep open the ophthalmic chart of Yahgee Documenta
→additional writing, save and close
a
Only possible at the entry from the Ophthalmology Outpatients List
J Med Syst (2010) 34:883–889
systems, (4) the ophthalmic medical records systems are
expensive in themselves, and (5) images saved in the
ophthalmic system will face a risk not to be transferred to
the next version of the present system or a new system at
the renewal of the electronic medical records systems.
Based on these considerations, we tried to solve two
major problems in ophthalmology practice by using Yahgee
Document View, which was introduced as documents and
images filing systems for the entire hospital. The first
problem in ophthalmology comes from many examinations
in many patients. The Ophthalmology Outpatients List was
developed using the Yahgee Workflow system to follow up
pre-doctor ophthalmic examinations in many patients. The
second problem derives from many images of ophthalmic
examinations and also from the presence of electronic-
resistant examinations such as visual acuity tests, visual
field tests, and strabismological tests. The images of fundus
camera, optical coherence tomography, ultrasonography,
and specular microscopy were exported and inputted into
the software, MaxFile, as a gateway to Yahgee Image. The
scanned images of perimetry, color vision tests, and
strabismus tests were directly uploaded to Yahgee Image.
The numerical data of visual acuity tests, autorefraction,
and non-contact tonometry were first inputted into a new
template, MaxFile ED, and then automatically exported to
designated boxes of the ophthalmic charts on the same date
of Yahgee Document. Images in Yahgee Image were
selected to transport to image-pasting boxes of the
ophthalmic charts.
Medical charts in paper are good at illustrating the
process of the disease by turning each page in a short
moment. On each page, doctors notice visual acuity,
intraocular pressure, and fundus photos to understand the
process in total. To reach this ideal state of medical records
in paper, we designed and developed the page-turning view
to show automatically the previous page on the left-hand
side and the present document on the right-hand side. By
889
clicking, the left-hand side view can go back to the further
previous documents.
The future problem is to preserve the images in the
process of renewal of the electronic medical records
system. The images of ophthalmic examinations are also
crucial for future clinical studies [2]. In this study,
ophthalmic images are controlled by the Yahgee Image
system which also covers radiographic and endoscopic
images for the entire hospital. This collective control of all
kinds of images in the hospital will lead to appropriate
transfer of the images to the future new system of electronic
medical records system.
In conclusions, the combination of Yahgee Ducument
View with Fujitsu medical records system allowed
ophthalmologists to examine the same volume of
patients over the same time frame in outpatients clinic
at the University Hospital as prior to the implementation
of the computerized filing systems in ophthalmology.
Ophthalmic medical charts and images created by
Yahgee Documemt View could be viewed and shared
by all the staffs in the hospital, together with other
documents and images such as radiographic, endoscopic,
ultrasonographic, and pathological images. Ophthalmic
medical charts with pasted images and automatically-
transported data, in line with other reports on medical
examinations, would improve the quality of information
and satisfy informational needs in the University
Hospital, thus leading to patients’ safety.
References
1. DeBry, P. W., Considerations for choosing an electronic medical
record for an ophthalmology practice. Arch. Ophthalmol. 119:590–
596, 2001.
2. Murphy, E. C., Ferris, F. L. III, and O’Donnell, W. R., An electronic
medical records system for clinical research and the EMR-EDC
interface. Invest. Ophthalmol. Vis. Sci. 48:4383–4389, 2007.
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