Characterizing Patient-Generated Clinical Data and Associated Implications for Electronic Health Records.
Patient-facing technologies are increasingly utilized for direct patient data entry for potential incorporation into the electronic health record. We analyzed patient-entered data during implementation of a patient-facing data entry technology using an online patient portal and clinic-based tablet computers at a University-based tertiary medical center clinic, including entries for past medical history, past surgical history, and social history. Entries were assessed for granularity, clinical accuracy, and the addition of novel information into the record. We found that over half of patient-generated diagnoses were duplicates of lesser or equal granularity compared to previous provider-entered diagnoses. Approximately one fifth of patient-generated diagnoses were found to meet the criteria for new, meaningful additions to the medical record. Our findings demonstrate that while patient-generated data provides important additional information, it may also present challenges including generating inaccurate or less granular information.
Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA.
Elliot G
EG
Arsoniadis
Department of Psychiatry, University of Minnesota, Minneapolis, MN, USA.
Rabindra
R
Tambyraja
Carolina Health Informatics Program, University of North Carolina, Chapel Hill, NC, USA.
Saif
S
Khairat
Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
Cyrus
C
Jahansouz
Fairview Health Services, Minneapolis, MN, USA.
Daren
D
Scheppmann
Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
Mary R
MR
Kwaan
Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA.
Gretchen
G
Hultman
Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA.
Genevieve B
GB
Melton
D000068598:Data Accuracy; D057286:Electronic Health Records / Q000145:classification* / Q000706:statistics & numerical data*; D016247:Information Storage and Retrieval / Q000145:classification / Q000379:methods; D062527:Meaningful Use / Q000706:statistics & numerical data*; D008487:Medical History Taking / Q000379:methods*; D008910:Minnesota; D033283:Patient Access to Records / Q000706:statistics & numerical data; D010358:Patient Participation / Q000706:statistics & numerical data*