Mismatched Symptoms Call EHR Data Integrity into Question

Low levels of agreement between patient-reported data and clinical documentation raise questions about EHR data integrity, accuracy, and trustworthiness.

A new study published in JAMA this month indicates that EHR data may not be completely aligned with what patients report to their providers. Eye health researchers from Michigan Medical School investigating EHR data integrity found that just 23.5 percent of EHRs contain exactly the same information as volunteered by patients, raising questions over the accuracy of clinical documentation.

Investigators from the Department of Ophthalmology and Visual Sciences at the University of Michigan Medical School studied 162 patients with eye health issues and found that EHRs rarely contained all of the information reported by the patients themselves on eye symptom questionnaires (ESQs). There was some agreement between ESQ and EHR data for all eight symptoms in 46.3 percent of the participants, but less than a quarter of EHRs were completely aligned with data from the ESQ. Notably, when the ESQ had reported three or more symptoms, the EHR never had exact symptom agreement.

"Symptom reporting was inconsistent between patient self-report on an ESQ and documentation in the EHR, with symptoms more frequently recorded on a questionnaire. These results suggest that documentation of symptoms based on EHR data may not provide a comprehensive resource for clinical practice or “big data” research." The researchers found "fair to poor agreement" in the data between the ESQs and EHRs with ESQs recording more positive occurrences in the eye symptom categories of glare, pain or discomfort, and redness...