One of my favorite medical school professors once told me, “The key to treating any patient can be found in a careful history.” Despite all of the technological and therapeutic advances of modern medicine, eliciting and accurately documenting a patient’s symptoms remain as important as ever. But have electronic medical record (EMR) systems helped or hindered our ability to do so? Valikodath et al1 shed light on this question in their observational study exploring the concordance between patient-reported symptoms and data documented in the EMR. For the 162 study patients evaluated in comprehensive ophthalmology and cornea clinics at a single academic center, the authors found poor agreement (κ range, −0.04 to 0.26) of symptom report between the Eye Symptom Questionnaire (used for patient self-report) and what was documented in the EMR. These inconsistencies were not clearly explained by patient, disease, or physician factors based on logistic regression models. Although the reason for the observed patient report–medical record mismatch is likely multifactorial, the authors caution that EMR documentation of patient symptoms may be inaccurate or incomplete. While this finding is worrisome in itself, it introduces a more macroscopic concern about EMR data integrity in general: can we trust what is written in our patients’ medical records?
Weng CY. Data Accuracy in Electronic Medical Record Documentation. JAMA Ophthalmol. Published online January 26, 2017. doi:10.1001/jamaophthalmol.2016.5562