Compared with clinician notes, EHR-based imaging orders are incomplete

Patient information in imaging orders sent via electronic health records (EHRs) is less complete and less reliable than that found in physician notes on the same patient in the same EHR. And the gap has ramifications for the accuracy of image interpretation, the appropriateness of the exam being ordered and the usefulness of clinical decision support tools, according to researchers led by Ronilda Lacson, MD, PhD, of Harvard University and the Center for Evidence-Based Imaging at Brigham and Women’s Hospital (BWH) in Boston. The team's study was published online Dec. 5 in the Journal of the American Medical Informatics Association.

The authors had four radiologists retrospectively review random selections of 139 completed orders for lumbar spine MRI exams and 176 abdominal CT exams. Their focus was on determining concordance and completeness of exam indication as compared with the relevant clinical information found in clinicians’ notes.

They found the EHR imaging requisitions were more likely to be incomplete (81 percent) than discordant (42 percent) compared to provider notes.

They also found the potential impact of discrepancy between clinical information in requisitions and provider notes was higher for the 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,” Lacson and colleagues concluded. “Such inaccuracies could also diminish the relevance of clinical decision support alerts if based on information in order requisitions.”