Abstract
ObjectiveTo evaluate the completeness of diagnosis recording in problem lists in a hospital electronic health record (EHR) system during the COVID-19 pandemic. DesignRetrospective chart review with manual review of free text electronic case notes. SettingMajor teaching hospital trust in London, one year after the launch of a comprehensive EHR system (Epic), during the first peak of the COVID-19 pandemic in the UK. Participants516 patients with suspected or confirmed COVID-19. Main outcome measuresPercentage of diagnoses already included in the structured problem list. ResultsPrior to review, these patients had a combined total of 2841 diagnoses recorded in their EHR problem lists. 1722 additional diagnoses were identified, increasing the mean number of recorded problems per patient from 5.51 to 8.84. The overall percentage of diagnoses originally included in the problem list was 62.3% (2841 / 4563, 95% confidence interval 60.8%, 63.7%). ConclusionsDiagnoses and other clinical information stored in a structured way in electronic health records is extremely useful for supporting clinical decisions, improving patient care and enabling better research. However, recording of medical diagnoses on the structured problem list for inpatients is incomplete, with almost 40% of important diagnoses mentioned only in the free text notes.
Highlights
The problem list is a feature of electronic health records (EHR) which provides a persistent summary of diagnoses and other health issues, in order to facilitate handovers and continuity of care [1,2]
We reviewed the problem list of 516 inpatients with suspected or confirmed COVID-19
The majority (290) were of White ethnicity, were Black, were South Asian, 58 were of mixed or other ethnicity and 23 had no ethnicity recorded. These patients had a combined total of 2841 diagnoses recorded in their EHR problem lists. 1722 additional diagnoses were identified as free text in electronic patient notes and transcribed into the problem list, increasing the mean number of recorded problems per patient from 5.51 to 8.14
Summary
The problem list is a feature of electronic health records (EHR) which provides a persistent summary of diagnoses and other health issues, in order to facilitate handovers and continuity of care [1,2]. This study sought to assess the completeness of recoding of problem list entries during the COVID-19 pandemic, one year after the installa tion of a comprehensive EHR system (Epic, May 2019 edition) at UCLH (University College London Hospitals) Trust. Sensitivity and specificity of diagnoses recorded in the problem list of electronic records, with medical charts as the standard for comparison Manual review of free text medical records. Structured data field for COVID-19 which was used consistently, but other information (such as diagnoses recorded in the problem list) were commonly recorded only as free-text electronic notes. Comprehensive retrospective chart review of this specific cohort of patients, and re covery of problem list data was required for EHR-derived COVID-19 datasets (see Appendix) and to support research at the trust to evaluate prognostic models for COVID-19 [22]. The aim of our audit was to assess whether information on key di agnoses was included in the problem list or stored only as unstructured free text notes
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