Ashfaq Hamza A, Lester Corey A, Ballouz Dena, Errickson Josh, Woodward Maria A
W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor.
Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor.
JAMA Ophthalmol. 2019 Aug 1;137(8):929-931. doi: 10.1001/jamaophthalmol.2019.1444.
Electronic health records (EHRs) contain an abundance of health information. However, researchers need to understand data accuracy to ask appropriate research questions.
To investigate the concordance of the names of medications for microbial keratitis in the structured, formal EHR medication list and the text of clinicians' progress notes.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study, conducted in the cornea section of an ophthalmology department in a tertiary care, referral academic medical center, examined the medications of 53 patients with microbial keratitis treated until disease resolution from July 1, 2015, to August 1, 2018. Documentation of medications was compared between the structured medication list extracted from the EHR server and medications written into the clinical progress note and transcribed by the study team.
Medication treatment for microbial keratitis.
Medication mismatch frequency.
The study sample included 24 men and 29 women, with a mean (SD) age of 51.8 (19.6) years. Of the 247 medications identified, 57 (23.1%) of prescribed medications differed between the progress notes and the formal EHR-based medication list. Reasons included medications not prescribed via the EHR ordering system (25 [43.9%]), outside medications not reconciled in the internal EHR medication list (23 [40.4%]), and medications prescribed via the EHR ordering system and in the formal list, but not described in the clinical note (9 [15.8%]). Fortified antimicrobials represented the largest category for medication mismatch between modalities (17 of 70 [24.3%]). Nearly one-third of patients (17 [32.1%]) had at least 1 medication mismatch in their record.
Almost 1 in 4 medications were mismatched between the progress note and formal medication list in the EHR. These findings suggest that EHR data should be checked for internal consistency before use in research.
电子健康记录（EHR）包含大量健康信息。然而，研究人员在提出恰当的研究问题之前需要了解数据准确性。
调查在结构化的、正式的EHR药物清单与临床医生病程记录文本中，微生物性角膜炎用药名称的一致性。
设计、设置和参与者：这项横断面研究在一家三级医疗转诊学术医学中心眼科的角膜科进行，研究了2015年7月1日至2018年8月1日期间接受治疗直至疾病痊愈的53例微生物性角膜炎患者的用药情况。将从EHR服务器提取的结构化药物清单与写入临床病程记录并由研究团队转录的药物进行比较。
微生物性角膜炎的药物治疗。
药物不匹配频率。
研究样本包括24名男性和29名女性，平均（标准差）年龄为51.8（19.6）岁。在识别出的247种药物中，病程记录与基于EHR的正式药物清单之间有57种（23.1%）处方药不同。原因包括未通过EHR医嘱系统开具的药物（25种[43.9%]）、内部EHR药物清单中未核对的外部药物（23种[40.4%]）以及通过EHR医嘱系统开具且在正式清单中但未在临床记录中描述的药物（9种[15.8%]）。强化抗菌药物是不同方式之间药物不匹配的最大类别（70种中的17种[24.3%]）。近三分之一的患者（17名[32.1%]）在其记录中有至少1种药物不匹配。
EHR中病程记录与正式药物清单之间近四分之一的药物存在不匹配。这些发现表明，在用于研究之前应检查EHR数据的内部一致性。
