- Researchers at the University of Michigan have found significant inconsistencies between patient-reported symptoms at ophthalmology clinics and documentation in their electronic medical record (EMR).
- Out 162 patients who self-reported on an eye symptom questionnaire, 34% had different reporting on the ESQ and EMR, according to a study published online today in JAMA Ophthalmology. Discrepancies were also seen for reporting glare (485), pain or discomfort (27%) and redness (25%).
- In addition, inconsistencies in symptom reporting increased with subsequent visits to the clinics, with more symptoms being reported in the questionnaire versus the EMR.
The findings could undermine the usefulness of EMR data not just in research studies but also for patient care. “If the EMR lacks relevant symptom information, it has implications for patient care, including communication errors and poor representation of the patient’s reported problems," the researchers wrote.
Most U.S. hospitals have already adopted certified EMRs, data from HHS' Office of the National Coordinator for Health IT shows. Yet physicians have been reporting a wide range of issues with EMR use, particularly with the amount of time it takes them to input data into the system.
Despite the current flaws with EMR data entry, "EMR systems already offer numerous benefits and will ultimately help us unlock what could be the next frontier of medicine—big data analysis, machine learning, and artificial intelligence, all of which depend on a vast but high-quality data set,” Christina Weng with Baylor College of Medicine wrote in an accompanying editorial. “It will certainly be worthwhile to continually improve on these systems and how we use them. After all, an EMR system is only as good as its data.”
The researchers recommended implementing self-report symptom questionnaires in the clinical setting to help counter EMR limitations and enhance overall documentation quality.