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Study Raises Doubts about Clinical Documentation Accuracy

Discrepancies between clinical documentation and patient-report data raise doubts about EHR data quality.

Data omissions threaten clinical documentation quality

Source: Thinkstock

By Kate Monica

- Researchers at the University of Michigan sought to investigate whether patient-reported eye symptoms were recorded as part of clinical documentation in EHR systems.

As part of a study published in JAMA Ophthalmology, Valikodath et al. compared the response of 162 participating patients to an eye symptom questionnaire (ESQ) to clinical documentation in the EHR system at the Kellogg Eye Center and observed significant inconsistencies with the disparities including symptoms of blurry vision, glare, pain, and redness.

These results demonstrate symptom reporting varies depending on the method used to record information, with patients reporting more symptoms on self-generated reports.

“We demonstrated that there is substantial discrepancy in the symptoms reported by patients on an ESQ and those documented in the EMR,” write the authors.

“Discordance in symptom reporting could be because of differences in terminology of symptoms between the patient and clinician or errors of omission, such as forgetting or choosing not to report or record a symptom,” they added. “Perhaps a more bothersome symptom is the focus of the clinical encounter, and other less onerous symptoms (eg, glare) are not discussed (or documented). However, even for the exclusive sensitivity analysis, we show that the ESQ and the EMR are inconsistently documented.”

The study ultimately found disparate reporting between ESQ and EHR reporting in 52.5 percent of participants for pain and 61.1 percent of patients for redness. Of the patients reporting symptoms inconsistently, 74.4 percent were recording their symptoms in a more detailed and acute manner on their ESQ reports as opposed to more their EHR records.

Researchers attributed potential causes of discordance between ESQ and EHR reporting to several causes.

First, researchers reasoned part of the inconsistency could be due to differences in the terminology used to describe symptoms between the patient and clinician.

Second, forgetting or choosing not to explicitly report a certain symptom to a provider could cause issues of omission.

As a result of the continued rise in EHR use, Valikodath et al. sought to verify whether EMR documentation measurably improves patient care and patient reporting. “The original intent of the EMR was not for complete documentation of the clinical encounter but for physicians note taking of their patient interactions. The EMR was implemented to integrate many sources of medical information,” they state.

As the authors note, clinicians have mixed views on the value of EHR reporting and its ability to capture necessary components of patient-to-provider interaction. The transition from paper-recorded medical records to EHR technology has revealed a few underlying issues including interruptions in clinical workflow, impersonal disruptions in the patient-provider relationship, time-consuming data entry, and lower productivity.

While EHR technology could potentially provide a host of advantages to both providers and patients, addressing pervasive issues is imperative to implementing the technology effectively. The Kellogg study sought to observe and tackle the issue of consistent reporting in order to make headway toward mitigating clinician’s concerns regarding widespread EHR use.

The study points to potential issues with the quality and accuracy of clinical documentation in EHR technology and highlights potential setbacks to using EHR data in research studies. Researchers suggest further investigation into the causes for these information inconsistencies in the future.

As a way to temporarily mitigate potential problems stemming from inconsistent or incomplete reporting, researchers suggest implementing self-reported questionnaires for symptoms in a hospital setting. Relying on both provider and patient reports will likely avoid clinical documentation omissions and offer a more comprehensive picture of a patient’s symptoms to improve diagnostics and accuracy of overall patient care.

This study is the latest in recent weeks raising doubts about the assumed benefits and advantages of EHR  use in improving patient care. Other studies have also reflected components of EHR technology that pose obstacles to patient engagement and cost-effectiveness.

While EHR technology has shown the potential to improve care coordination, transitions of care, and clinical decision support, EHR optimization still remains a top priority for the healthcare industry as a whole. 



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