All patient symptoms don’t make it into the EHR, study finds

Blue eye
Symptoms patients reported on a questionnaire at an eye center frequently did not match what was recorded in the EHR.

There’s a disconnect between what patients report as symptoms and what information is recorded in the electronic health record (EHR), a new study has found.

Researchers found that symptoms patients reported on a questionnaire at an eye center, from blurry vision to pain or discomfort, frequently did not match what was recorded in the EHR, according to the study published in JAMA Ophthalmology. Most often patients reported symptoms in the questionnaire that were not in the EHR.

Reasons for the inconsistencies were not clear from the study, but the authors said a physician’s experience, workload and use of a medical scribe were not significant factors. "As noted by other authors, inconsistency may rather be due to time constraints, system-related errors and communication lapses," said the researchers from the Department of Ophthalmology and Visual Sciences at the University of Michigan Medical School in Ann Arbor.

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RELATED: EHR copy and paste could land you in hot water

Although not mentioned in the research, doctors who "cut and paste" from templates into an individual EHR record can create errors and omissions. Providers say the shortcut is essential for workflow and efficiency, but providers who do it could be in violation of the False Claims Act.  

The researchers compared patients’ answers on a questionnaire that asked about the severity of eight eye symptoms with the information recorded in EHRs for 162 adult patients who were seen at clinics at the university’s Kellogg Eye Center. They found discrepancies—for instance, 33.8% of patients’ information on blurry vision did not match between the questionnaire and the EHR.

The disconnect may have implications for both patient care and the accuracy of EHR data for research studies, the researchers said. One way to make reporting more consistent would be the use of a standardized template to collect patient information, which could then be uploaded into the EHR, they said.

As is often the case, it is much easier to identify problems than it is to find solutions, Christina Y. Weng, M.D., from the Cullen Eye Institute, Department of Ophthalmology at Baylor College of Medicine in Houston, Texas, wrote in a related commentary. When practices have patients use paper questionnaires to record symptoms, those documents may be overlooked when scanned into the EHR, she said. However, some patients may have trouble entering their data electronically.

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