Integrity of clinical information in computerized order requisitions for diagnostic imaging

Abstract

Objective Assess information integrity (concordance and completeness of documented exam indications from the electronic health record [EHR] imaging order requisition, compared to EHR provider notes), and assess potential impact of indication inaccuracies on exam planning and interpretation. Methods This retrospective study, approved by the Institutional Review Board, was conducted at a tertiary academic medical center. There were 139 MRI lumbar spine (LS-MRI) and 176 CT abdomen/pelvis orders performed 4/1/2016-5/31/2016 randomly selected and reviewed by 4 radiologists for concordance and completeness of relevant exam indications in order requisitions compared to provider notes, and potential impact of indication inaccuracies on exam planning and interpretation. Forty each LS-MRI and CT abdomen/pelvis were re-reviewed to assess kappa agreement. Results Requisition indications were more likely to be incomplete (256/315, 81%) than discordant (133/315, 42%) compared to provider notes (p < 0.0001). Potential impact of discrepancy between clinical information in requisitions and provider notes was higher for radiologist’s interpretation than for exam planning (135/315, 43%, vs 25/315, 8%, p < 0.0001). Agreement among radiologists for concordance, completeness, and potential impact was moderate to strong (Kappa 0.66-0.89). Indications in EHR order requisitions are frequently incomplete or discordant compared to physician notes, potentially impacting imaging exam planning, interpretation and accurate diagnosis. Such inaccuracies could also diminish the relevance of clinical decision support alerts if based on information in order requisitions. Conclusions Improved availability of relevant documented clinical information within EHR imaging requisition is necessary for optimal exam planning and interpretation.

Can emergency department provider notes help to achieve more dynamic clinical decision support?

“…The differences in rates of positive and negated attributes between note and CDS sources did not reach statistical significance, likely because of the lack of power in the identified sample size. This outcome also reflects findings in a recent study that showed discordance and incompleteness in order requisition indications compared to data from clinical notes, with potential impacts on the selection of imaging protocol to address the indication as well as the interpretation of the imaging studies 3 …”

“…This outcome also reflects findings in a recent study that showed discordance and incompleteness in order requisition indications compared to data from clinical notes, with potential impacts on the selection of imaging protocol to address the indication as well as the interpretation of the imaging studies. 3 This study illustrates that data entered in the EHR and via CDS fall short in multiple dimensions of data quality including correctness and concordance. 29 Future work is needed to identify methods of improving the quality of data in the EHR and CDS tools, as well as performing validity checks at the point of data entry.…”

“…This is in addition to the potential quality of care risks from discordant structured information entered during the provider order entry process, including erroneous CDS guidance, inappropriate imaging protocol selection for the condition being evaluated, and negative impacts on imaging interpretation. 2,3 CDS can effectively improve ED practice. [7][8][9][10][11] The National Emergency X-Radiography Utilization Study (NEXUS) 12 and the Canadian C-Spine Rule 13 are well-validated decision rules based on the highest quality evidence to assist emergency clinicians in reducing unnecessary c-spine imaging.…”

“…This process leads to significant workflow interruptions and redundancy of documentation within the same EHR. Incomplete or conflicting information resulting from these redundancies may adversely affect the quality of patient care including propagation of misinformation, lack of ability for providers to identify pertinent information, 2 accuracy of imaging protocol assigned, quality of radiologist's interpretation, 3 or secondary analyses including guideline adherence and research. Low sensitivity of CDS activation may lead to missed opportunities to suggest more appropriate diagnostic studies.…”

“…A crisis of alert fatigue and usability deficits may ensue if the implementation of these CDS tools relies on independent provider data entry and does not leverage existing electronic health record data to improve the specificity of their activation. This is in addition to the potential quality of care risks from discordant structured information entered during the provider order entry process, including erroneous CDS guidance, inappropriate imaging protocol selection for the condition being evaluated, and negative impacts on imaging interpretation 2,3 …”