Fuzzy records

By | February 6, 2017
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Medical records and stethoscope

Symptoms that patients describe to doctors may not always be documented in electronic medical records, a small study suggests. 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 Paula Anne Newman-Casey, an ophthalmologist at the Kellogg Eye Center. “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,” she added.