Not everything patients tell their physicians may be making its way into their electronic health records.
According to a recent study of eye clinic patients in JAMA Ophthalmology, researchers found "inconsistencies between patient self-report on an eye symptom questionnaire (ESQ) and documentation in the EMR." Issues such as blurry vision, pain and discomfort often did not match what was supposed to have been in the patients' records. In fact, most of the practice's patients said that information they presented to the clinic did not get reported in their file.
Disagreement about the missing reported symptoms was defined as either a negative symptom report or no mention of a symptom in the EHR for patients who reported moderate to severe symptoms, JAMA noted in its explanation of the study's methodology.
These metrics were gained from a total of 162 patients (324 eyes). And while the study was limited to one location in a specific care sector, there's probably a bit of truth for healthcare as a whole and its use of electronic health records. This is not a cynical observation, especially based on these results, and likely more systematic of the whole than may be portrayed here.
At the participant level, 34 percent (54 of 160) had discordant reporting of blurry vision between the form and the EHR. Likewise, documentation was discordant for reporting glare (48 percent), pain or discomfort (27 percent) and redness (25 percent), with poor to fair agreement.
Thus, we see that symptom reporting was inconsistent between patient self-report on a form and documentation in the EHR, with symptoms more frequently recorded on a questionnaire. These results suggest that documentation of symptoms based on EHR data may not provide a comprehensive resource for clinical practice or Big Data research.
A physician's experience, workload and use of a medical scribe were not significant factors in the reason for improper documentation, the authors said.
"As noted by other authors, inconsistency may rather be because of time constraints, system-related errors and communication lapses," said the researchers from the Department of Ophthalmology and Visual Sciences at the University of Michigan Medical School in Ann Arbor.
The disconnect may have implications for both patient care and the accuracy of EHR data for research studies, the researchers said. A more consistent result would likely come from the use of a standardized template to collect patient information, which could then be uploaded into the EHR, researchers suggested.
A suggested solution to the problem? Stop using paper forms — those documents may be overlooked when scanned into the EHR or may not be properly reviewed.
