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Patient-reported data often excluded from EHR documentation

A recent eye health study found that patient-reported data doesn’t always get recorded in a patient’s electronic health record (EHR), raising questions about the accuracy of clinical documentation.

Investigators from the Department of Ophthalmology and Visual Sciences at the University of Michigan Medical School compared patient-reported symptoms with the symptoms recorded in the EHR. The researchers found that of 162 patients surveyed, there were only 38 exact matches between the patient-reported symptoms and the EHR documentation. When the patient reported three or more symptoms, the EHR never had exact agreement.

While the major mismatch between patient-reported data and EMR documentation was the failure to capture patient-reported symptoms, there were also instances of symptoms incorrectly being recorded for patients who did not report that problem. For example, blurry vision was inaccurately identified as a symptom for 29 patients, but was only accurately recorded for 26 patients.

The inconsistency between patient-reported data and clinical documentation led the researchers to conclude, “documentation of symptoms based on [EHR] data may not provide a comprehensive resource for clinical practice or ‘big data’ research.” In other words, since EHR data may not provide a complete view of a patient’s health, it can impact the quality of care the patient receives. Inaccuracies in EHR data could also preclude its use in research studies until it is consistent with patient-reported data.

Maria Woodward, M.D., assistant professor of ophthalmology and visual sciences at the University of Michigan, said in a release, “Many parties in health care use the electronic health records now, and they expect the data to accurately reflect the interaction with the doctor.”

Woodward said neither the patient nor doctor is at fault for the inconsistency, but that it highlights an opportunity to improve doctor-patient communication. Woodward said by using a self-reporting system prior to a visit, the doctor and patient can spend more time talking about symptom management rather than identifying symptoms.