Eye problems: What patients say vs. what doctors see

You’re not seeing things.

A comparison of a patient’s self-reported eye symptoms with their electronic health record (EHR) shows clear discrepancies, according to a new study published in JAMA Ophthalmology.

“Many parties in healthcare use the electronic health records now and they expect the data to accurately reflect the interaction with the doctor,” says Maria Woodward, MD, MS, assistant professor of ophthalmology and visual sciences at the University of Michigan in a press release. “The concern highlighted by this research is that important symptoms may be overlooked. If a patient has severe symptoms, all of those symptoms should be documented and addressed.”

Researchers from the University of Michigan Kellogg Eye Center analyzed the symptoms of 162 patients who completed a pre-appointment questionnaire. The doctors were not told about the surveys or that their patient notes would be reviewed for comparison.

Woodward and colleagues found a distinction between what patients say versus what clinicians wrote. Only 38 patients had “exact agreement” between and their survey and their medical record. The biggest problem: symptom reporting.

Woodward says the disconnected is understandable, as the doctor-patient relationship is more nuanced than a point-by-point checklist or what is recorded in the medical record. Patients may not disclose all of their symptoms, record keeping takes time and the entire conversation doesn’t need to be documented.

But, she cautioned those discrepancies could have long-lasting and unintended consequences as EHRs are used to guide future patient treatment. It could also lead to inaccurate conclusions if the anonymized data is used for clinical research.

Woodward says the study highlights the need for better communication. Pre-appointment questionnaires could help doctors evaluate the patient’s symptoms that could guide the conversation, improve outcomes and even identify concerns that would have otherwise gone unnoticed. 

Topics: Clinical , Technology & IT