Patient information incomplete in EHR-based imaging orders compared to clinician notes

Imaging orders sent via electronic health records (EHRs) have less complete—and consequently less reliable—patient information than those found in physician notes on the same patient in the same EHR, according to research published online Dec. 5 in the Journal of the American Medical Informatics Association. 

For the study, four radiologists reviewed random selections of 139 completed orders for lumbar spine MRIs and 176 CT exams. Particularly, the aim was to determine concordance and completeness of exam indication as compared with the clinicians’ notes containing relevant clinical information.  

Ronilda Lacson, MD, PhD, of Harvard University and the Center for Evidence-Based Imaging at Brigham and Women’s Hospital in Boston, and colleagues found the EHR imaging requisitions to more likely be incomplete (81 percent) than discordant (42 percent) compared to clinicians’ notes.  

The researchers also found potential impact of discrepancy between clinical information in requisitions and provider notes was higher for radiologist’s interpretation than for exam planning—43 percent vs. 8 percent.  

“Indications in EHR order requisitions are frequently incomplete or discordant compared to physician notes, potentially impacting imaging exam planning, interpretation and accurate diagnosis,” the researchers wrote. “Such inaccuracies could also diminish the relevance of clinical decision support alerts if based on information in order requisitions.”