Study Highlights Major Discrepancies Between Electronic Medical Records and Self-Reported Symptoms

A recent study found discrepancies between self-reported records of patients’ symptoms reported on questionnaires and electronic medical records (EMR).

The study was conducted to determine the accuracy of patient symptom documentation, and included 162 patients from the Kellogg Eye Center. Of the 162, 62.3% were female, 84.9% were white, and the mean age was 56.6 years. Participants completed an Eye Symptom Questionnaire (ESQ), and researchers compared self-reported symptoms to documentation in the EMR.
_______________________________________________________________________________________________
RELATED CONTENT
Regular Coffee Consumption May Protect Eyesight
Prevalence of Diabetes and Eye Conditions May Be Intertwined
_______________________________________________________________________________________________

The researchers analyzed agreement of symptoms using k statistics and McNemar tests. They defined disagreement as no mention of symptom or negative symptom report in the EMR, but record of symptom in the ESQ. In addition, researchers used logistic regression to investigate if patient factors, physician characteristics or diagnoses were associated with disagreement of blurry vision, pain, discomfort, or redness symptoms between the EMR and ESQ.

Overall, 33.8% of cases showed disagreements between reporting of blurry vision between the ESQ and EMR. In addition, documentation was discordant for reporting glare (48.1%), pain or discomfort (26.5%), and redness (24.7%), with poor to fair agreement.

“Exact agreement between self-report and EMR documentation dropped to zero when patients reported 3 or more symptoms on the ESQ,” the researchers wrote.

In addition, return visits where the patient reported blurry vision on the ESQ were less likely to be recorded in the EMR compared to new visits.

“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 inconsistencies imply caution for the use of EMR data in research studies,” the researchers concluded.

—Melissa Weiss

Reference:

Valikodath NG, Newman-Casey PA, Lee PP, et al. Agreement of ocular symptom reporting between patient-reported outcomes and medical records [published online January 26, 2017]. JAMA Opthalmology. doi:10.1001/jamaophthalmol.2016.5551.