Poorly Matched Symptoms on Paper vs. EHR Casts Doubt on Accuracy of EHRs

Self-reported symptoms of ocular problems were incorrectly transferred from a paper questionnaire into an electronic health record (EHR) roughly one-third of the time, according to results of a small study conducted in one clinic.

“While this finding is worrisome in itself, it introduces a more macroscopic concern about EMR data integrity in general: can we trust what is written in our patients’ medical records?” wrote the University of Michigan researchers who conducted the study, in JAMA Ophthalmology.

The study itself involved 162 patients who visited a single clinic between October 2015 and January 2016. All of the patients were given paper questionnaires that included check boxes listing common ocular symptoms, such as blurred vision, redness, itchiness, and glare. The researchers then compared the symptoms checked off on the form against the symptoms that were eventually listed in the patients’ electronic records. Around 34 percent of the time, researchers found that when blurry vision was listed on the paper, it was not entered accordingly in the EHR.

Likewise, documentation was discordant for reporting glare 48.1 percent of the time; pain or discomfort 26.5 percent of the time; and redness 24.7 percent of the time, researchers found.

“Because the electronic health record allows researchers, payers, and administrators to extract information from the medical record in a way that has never been previously possible, the implications of capturing patient data in the most accurate way becomes much more imperative,” study co-author Dr. Paula Anne Newman-Casey, an ophthalmologist at the University of Michigan’s Kellogg Eye Center in Ann Arbor, told Reuters.

Although the study is small the authors warn that the inaccuracies present in this study could have implications for researchers who use EHR data for data mining and other research.

Click here to read the study, and here to read accompanying commentary.

Mary Butler is the associate editor at The Journal of AHIMA.

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