What happens if your medical records are incomplete? – Teach daily

Your entire medical journey lives in digital health records, but how do you know if those records are wrong, incomplete, or missing important information? That’s the focus of research by Varadraj Gurupur, associate professor in the UCVF School of Global Health Management and Informatics.

His latest project created an algorithm that can predict and measure the incompleteness of electronic health records — in everything from lab results to disease diagnoses and medical histories to prescription records.

He says the missing information in electronic health records (EHRs) kept by hospitals and doctors’ offices is like an infusion tube. If you don’t know where the leak is, you can’t fix it, and soon the house could be flooded. The same risks can occur in healthcare. A recent study by Gurupur revealed that a critical percentage of digital health records contain missing information.

Its algorithm uses mathematics and computer science to answer the question, “Where does the water leak?” He says. The analysis by Gurupur and his team found that the level of incompleteness per year varies and there is no pattern to where missing data occurs. Its algorithm helps identify the features that tend to be most incomplete – areas of the water pipe that are most vulnerable and can break frequently.

His previous studies have documented that the biggest causes of loss of health information are communication and education. Communication between patients and their providers is not always clear – especially if the patient is interacting with a healthcare professional who does not speak their native language. Cultural barriers may prevent patients from sharing important information with their providers. Digital technology also creates its own challenges. Providers may not fill out electronic records until the end of the day – and forget what the patient said or not accurately find it in their notes. Hospitals and clinics are switching electronic health record systems, requiring extensive new retraining that leads to a learning curve for providers. Some healthcare workers, especially those who didn’t grow up with technology, may not be adept at using electronic health records.

“Missing health information can sometimes be as simple as someone not being sure which button to press in the new system,” Gurupur says.

Dr. Ayaan Nasir is completing his 20MD residency in Internal Medicine at Mayo Clinic in Jacksonville, Florida. As an undergraduate and UCSD student, Nasir did research with Gurupur on health informatics. Before entering the medical field, Nasir worked in the financial field and says he was amazed at the difference in quality control and data accuracy teams between bank records and health records. These contradictions inspired him to make improving health informatics the subject of his two-year Focused Inquiry and Research Experience (FIRE) project at the School of Medicine, with Gurupur serving as his research mentor.

His residency furthered his passion for improving health informatics.

“When I see a patient, what I put in the electronic health record reflects one episode of their care,” he says. “But this information will guide every medical decision in the future. That’s why electronic records must be complete.”

Gurupur gave this example to highlight the impact of incomplete health data. A patient with limited English skills visits a new caregiver who does not speak the patient’s native language. Due to his communication challenges and the rush of clinical practice, the patient forgets to mention that he or she is on a specific medication for type 2 diabetes. There is nothing about previous diabetes treatment in the electronic health record, so the provider prescribes a standard medication in a standard dose for that condition. Now the patient can take twice the recommended amount.

Medicine is looking for ways to use more big data – artificial intelligence – to diagnose and provide more evidence-based treatments. Nasir points out that this computer analysis is based on complete patient data.

“When it comes to medicine, you’re just as good as your data,” he says.

Gurupur says developing reliable algorithms for missing data is also important for health systems. Recent studies have shown that hospitals can lose an average of $5-8 million annually due to missing data affecting insurance reimbursement rates. With the algorithm, hospital leaders can figure out exactly where the missing information is coming from — a particular floor, department or service — and address it.

Gurupur and Nasir believe that health informatics is at a critical tipping point. Health systems rely on electronic records but must develop ways to ensure that all information they collect is complete and accurate. Nasser holds a master’s degree in health informatics from Northwestern University and notes that graduate medical training programs show the growing importance of using data to deliver better patient care. He believes that future health technology will improve care even further – for example, computers will translate conversations between providers and patients into an electronic record, reducing the need for providers to manually enter data after each visit.

“We are only at the beginning of this transition,” he says. “It’s exciting to be a part of this work.”

Story source:

Materials Introduction of University of Central Florida. Original by Wendy Sarobi. Note: Content can be modified by style and length.

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