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Joel Kaluzny, Wei-Chun Lin, Jimmy S Chen, Michael F Chiang, Michelle Hribar; Electronic health record medication list accuracy in glaucoma patients. Invest. Ophthalmol. Vis. Sci. 2021;62(8):1609.
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The electronic health record (EHR) is a critical part of patient care. EHR data has potential for use in large-scale research. However, the quality of this research is reliant on accuracy of the data in the EHR. Our aim is to assess the accuracy of the EHR in capturing glaucoma patients’ current ophthalmologic medication by comparing their documentation in the medication list and in progress notes.
Progress notes and medication list data from the EHR were extracted by 3 independent reviewers for encounters containing ICD codes with the word “glaucoma” at the Casey Eye Institute from 1/1/2019 to 12/31/2019. All ophthalmologic medications were included and further stratified according to type: prescription eye drops/ointment, over-the-counter (OTC) eye drops/ointment, and oral medications. For each encounter analyzed, the current medication list was manually abstracted from the progress note text and compared to the EHR medication list at the time of the encounter. A subset of 20 encounters were used to generate an analysis protocol and as cross-validation amongst reviewers (96.4% agreement).
Overall, 9066 encounters met the inclusion criteria. 150 encounters were randomly selected for analysis. Prescription medications were most common (93% of encounters), followed by OTC medications (43%), and oral medications (9%). The average number of ophthalmic medications per encounter was 1.97, while the average number of discrepancies per encounter was 0.55. 57% of encounters contained some discrepancy. Prescription medications were more frequently included in the medication list but left out of the progress notes, whereas, OTC medications were more commonly mentioned in the notes, but left out of the medication lists. Overall, a large portion of encounters (26%) had 2 or more medication list discrepancies.
Medication discrepancies were found to be present in a large percentage of encounters. Approximately 1 in 4 medication entries had a discrepancy between the medication list and the note. These findings demonstrate significant inconsistencies in the EHR medication records, which may affect research that uses this data. There is opportunity for improving the accuracy of medication documentation in the EHR which could have benefits for both research as well as clinical care.
This is a 2021 ARVO Annual Meeting abstract.
Summary of medication list mismatches
Summary of medication mismatches across 150 encounters analyzed.
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