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Spuhl J, Doing-Harris K, Nelson S, Estrada N, Del Fiol G, Weir C. Concordance of Electronic Health Record (EHR) Data Describing Delirium at a VA Hospital. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 2014 Nov 14; 2014:1066-71.
BACKGROUND: Delirium is a common syndrome in elderly hospitalized patients that is correlated with poor outcomes and higher costs yet health care teams often overlook its diagnosis and treatment. Poor data quality in EHR systems can be contributing to this as a common tool teams use to communicate and record data about their patients. METHODS: Data were gathered from 30 patients chosen randomly that spanned various data domains in the EHR. These were analyzed for concordance as an indicator of data quality. RESULTS: Concordance was high between the physician and nursing narrative documentation. The other domains of data were drastically less concordant. DISCUSSION: The low concordance between structured and narrative data domains suggests that clinicians are forgoing the features available in modern EHR systems and opting to work in narrative. For informatics, this can be troubling as narrative data are difficult to compute.