|
 To test out how well the records match reality, researchers compared
symptoms that 162 patients checked off on paper-based questionnaires
with the information entered in patients’ electronic charts at eye
clinics.
Roughly one-third of the time, data on blurry vision from the paper
questionnaires didn’t match the electronic records, researchers
report in JAMA Ophthalmology. Symptom information also didn’t match
for glare 48 percent of the time and was discordant in 27 percent of
cases for pain and 25 percent for redness.
“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,” said study co-author Dr. Paula Anne Newman-Casey, an
ophthalmologist at the University of Michigan’s Kellogg Eye Center
in Ann Arbor.
“The data captured in the electronic health record, if it is highly
accurate, can be used to improve the quality of care that we deliver
in a way that data captured on disparate paper charts never made
possible,” Newman-Casey added by email.
In theory, the promise of electronic health records is that they can
help improve the quality of care and lower costs in part by reducing
room for errors. Most U.S. doctors and hospitals now use electronic
records, though paper remains common for patient symptom
questionnaires.
For the study, researchers examined paper copies of eye symptom
questionnaires completed by patients visiting eye clinics between
October 2015 and January 2016.
Patients rated the severity of common eye issues within the previous
week.
Blurry vision was the most common complaint, but when patients
reported blurry vision on the questionnaires, the electronic health
record correctly noted this in 60 cases but failed to include it in
25 cases.
For patients who didn’t report blurry vision, the electronic records
accurately noted this in 26 cases but mistakenly identified this as
a problem for 29 patients.
Mismatches were also common for redness, pain, glare, itching,
gritty sensation and sensitivity to light. More often than not, the
error involved electronic records failing to capture symptoms
patients noted on the paper questionnaires.
[to top of second column] |
The study is small and only included patients within a single clinic
system, the authors note.
Still, the results suggest that electronic health records may not
always be reliable tools for clinicians treating patients or for
researchers mining data, the authors conclude.
When patient symptoms are missing from electronic records, it can
also prompt clinicians to go in the wrong direction looking for a
diagnosis and delay patients getting the care they actually need,
Dr. Christina Weng of the Cullen Eye Institute and Baylor College of
Medicine in Houston writes in an accompanying editorial.
“Data accuracy in patient medical records is absolutely critical,”
Weng said by email.
“Documented signs and symptoms play an important role in efficiently
steering providers towards the correct diagnosis and treatment, and
medical records also serve as a means of communication between
members of a patient’s healthcare team,” Weng added. “Any
inaccuracies in the record could potentially threaten or delay
patient care.”
SOURCE: http://bit.ly/2ktpZ4S and http://bit.ly/2kTwr2N JAMA
Ophthalmology, online January 26, 2017.
[© 2017 Thomson Reuters. All rights
reserved.] Copyright 2017 Reuters. All rights reserved. This material may not be published,
broadcast, rewritten or redistributed.
 |
