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Research Article Open Access
Electronic health record (EHR) problem lists are extremely important, and yet they are often incomplete and out of date. We compared the EHR problem list to a self-reported problem list obtained via a tablet-administered questionnaire to identify potential synergy. We conducted a retrospective review comparing the EHR problem list to the patients’ self-reported problem list during the year of 2011. To confirm the accuracy of patient self-reports, we also analyzed medication lists, and laboratory results for two selected conditions, hypercholesterolemia and diabetes mellitus. Overall, 1472 patients at the Massachusetts General Hospital (MGH) used the tablet questionnaire. Of these, 843 (57.27%) had no problem reported in the EHR and some problem reported on the tablet (“Tablet Only”); 42 patients (2.85%) had no problem reported on the tablet or in the EHR (“None”); 17 patients (1.15%) had some problem reported in the EHR and no problem reported on the tablet (“LMR Only”); and 570 patients (38.72%) had some problem reported both on the tablet and in the LMR (“Both”). Overall, we studied 59 conditions, of which twelve had enough patients to run Chi Square analysis. Of the 12 conditions analyzed, 10 were significant, and 9 out of 10 conditions favored the tablet-administered questionnaire. Medication lists and laboratory results were reviewed to confirm the presence of the selected conditions. We reviewed the EHR problem list one year after the study was initiated to update the conditions under study. The additional data corroborated 107 additional self-reported conditions in 97 patients. In summary, a self-administered tablet questionnaire is an acceptable method for collecting the medical history. When combined with the EHR problem list, self-reported medical history is optimal for obtaining the most accurate problem list possible.
Electronic health record, Healthcare, Patients, General Medicine