TY - JOUR
T1 - The Impact of Documentation Workflow on the Accuracy of the Coded Diagnoses in the Electronic Health Record
AU - Hwang, Thomas S.
AU - Thomas, Merina
AU - Hribar, Michelle
AU - Chen, Aiyin
AU - White, Elizabeth
N1 - Publisher Copyright:
© 2023 American Academy of Ophthalmology
PY - 2024/1/1
Y1 - 2024/1/1
N2 - Objective: To determine the impact of documentation workflow on the accuracy of coded diagnoses in electronic health records (EHRs). Design: Cross-sectional study. Participants: All patients who completed visits at the Casey Eye Institute Retina Division faculty clinic between April 7, 2022 and April 13, 2022. Main Outcome Measures: Agreement between coded diagnoses and clinical notes. Methods: We assessed the rate of agreement between the diagnoses in the clinical notes and the coded diagnosis in the EHR using manual review and examined the impact of the documentation workflow on the rate of agreement in an academic retina practice. Results: In 202 visits by 8 physicians, 78% (range, 22%–100%) had an agreement between the coded diagnoses and the clinical notes. When physicians integrated the diagnosis code entry and note composition, the rate of agreement was 87.9% (range, 62%–100%). For those who entered the diagnosis codes separately from writing notes, the agreement was 44.4% (22%–50%, P < 0.0001). Conclusion: The visit-specific agreement between the coded diagnosis and the progress note can vary widely by workflow. The workflow and EHR design may be an important part of understanding and improving the quality of EHR data. Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
AB - Objective: To determine the impact of documentation workflow on the accuracy of coded diagnoses in electronic health records (EHRs). Design: Cross-sectional study. Participants: All patients who completed visits at the Casey Eye Institute Retina Division faculty clinic between April 7, 2022 and April 13, 2022. Main Outcome Measures: Agreement between coded diagnoses and clinical notes. Methods: We assessed the rate of agreement between the diagnoses in the clinical notes and the coded diagnosis in the EHR using manual review and examined the impact of the documentation workflow on the rate of agreement in an academic retina practice. Results: In 202 visits by 8 physicians, 78% (range, 22%–100%) had an agreement between the coded diagnoses and the clinical notes. When physicians integrated the diagnosis code entry and note composition, the rate of agreement was 87.9% (range, 62%–100%). For those who entered the diagnosis codes separately from writing notes, the agreement was 44.4% (22%–50%, P < 0.0001). Conclusion: The visit-specific agreement between the coded diagnosis and the progress note can vary widely by workflow. The workflow and EHR design may be an important part of understanding and improving the quality of EHR data. Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
KW - Data quality
KW - Electronic health records
KW - Problem-oriented charting
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U2 - 10.1016/j.xops.2023.100409
DO - 10.1016/j.xops.2023.100409
M3 - Article
AN - SCOPUS:85178014027
SN - 2666-9145
VL - 4
JO - Ophthalmology Science
JF - Ophthalmology Science
IS - 1
M1 - 100409
ER -