Assessing provider-generated free-text quality in EHR-Integrated Handoff Notes

Elliot G. Arsoniadis; Steven J. Skube; Treva M. Bjerke; Bryan Jarabek; Genevieve B. Melton

doi:10.3233/978-1-61499-830-3-999

Assessing provider-generated free-text quality in EHR-Integrated Handoff Notes

Elliot G. Arsoniadis, Steven J. Skube, Treva M. Bjerke, Bryan Jarabek, Genevieve B. Melton

Surgery

Research output: Chapter in Book/Report/Conference proceeding › Conference contribution

3 Scopus citations

Abstract

Handoff notes are increasingly integrated within electronic health record (EHR) systems and often contain data automatically generated from the EHR and free-text narratives. We examined the quality of data entered by providers in the free-text portion of our institutional EHR handoff tool. Overall, 65% of handoff notes contained at least one error (average 1.7 errors per note). Most errors were omissions in information around patient plan/management or assessment/diagnosis rather than entry of false data. Factors associated with increased error rate were increasing hospital day number; weekend note; medical (vs. surgical) service team; and authorship by a medical student, first or fourth year resident physician, or attending physician. Our findings suggest that errors are common in handoff notes, and while these errors are not completely false data, they may provide individuals caring for patients an inaccurate understanding of patient status.

Original language	English (US)
Title of host publication	MEDINFO 2017
Subtitle of host publication	Precision Healthcare through Informatics - Proceedings of the 16th World Congress on Medical and Health Informatics
Editors	Adi V. Gundlapalli, Jaulent Marie-Christine, Zhao Dongsheng
Publisher	IOS Press BV
Pages	999-1003
Number of pages	5
ISBN (Electronic)	9781614998297
DOIs	https://doi.org/10.3233/978-1-61499-830-3-999
State	Published - 2017
Event	16th World Congress of Medical and Health Informatics: Precision Healthcare through Informatics, MedInfo 2017 - Hangzhou, China Duration: Aug 21 2017 → Aug 25 2017

Publication series

Name	Studies in Health Technology and Informatics
Volume	245
ISSN (Print)	0926-9630
ISSN (Electronic)	1879-8365

Other

Other	16th World Congress of Medical and Health Informatics: Precision Healthcare through Informatics, MedInfo 2017
Country/Territory	China
City	Hangzhou
Period	8/21/17 → 8/25/17

Bibliographical note

Publisher Copyright:
© 2017 International Medical Informatics Association (IMIA) and IOS Press.

Keywords

Electronic health records
Patient handoff
Patient transfer

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10.3233/978-1-61499-830-3-999

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Arsoniadis, E. G., Skube, S. J., Bjerke, T. M., Jarabek, B., & Melton, G. B. (2017). Assessing provider-generated free-text quality in EHR-Integrated Handoff Notes. In A. V. Gundlapalli, J. Marie-Christine, & Z. Dongsheng (Eds.), MEDINFO 2017: Precision Healthcare through Informatics - Proceedings of the 16th World Congress on Medical and Health Informatics (pp. 999-1003). (Studies in Health Technology and Informatics; Vol. 245). IOS Press BV. https://doi.org/10.3233/978-1-61499-830-3-999

Assessing provider-generated free-text quality in EHR-Integrated Handoff Notes. / Arsoniadis, Elliot G.; Skube, Steven J.; Bjerke, Treva M. et al.
MEDINFO 2017: Precision Healthcare through Informatics - Proceedings of the 16th World Congress on Medical and Health Informatics. ed. / Adi V. Gundlapalli; Jaulent Marie-Christine; Zhao Dongsheng. IOS Press BV, 2017. p. 999-1003 (Studies in Health Technology and Informatics; Vol. 245).

Research output: Chapter in Book/Report/Conference proceeding › Conference contribution

Arsoniadis, EG, Skube, SJ, Bjerke, TM, Jarabek, B & Melton, GB 2017, Assessing provider-generated free-text quality in EHR-Integrated Handoff Notes. in AV Gundlapalli, J Marie-Christine & Z Dongsheng (eds), MEDINFO 2017: Precision Healthcare through Informatics - Proceedings of the 16th World Congress on Medical and Health Informatics. Studies in Health Technology and Informatics, vol. 245, IOS Press BV, pp. 999-1003, 16th World Congress of Medical and Health Informatics: Precision Healthcare through Informatics, MedInfo 2017, Hangzhou, China, 8/21/17. https://doi.org/10.3233/978-1-61499-830-3-999

Arsoniadis EG, Skube SJ, Bjerke TM, Jarabek B, Melton GB. Assessing provider-generated free-text quality in EHR-Integrated Handoff Notes. In Gundlapalli AV, Marie-Christine J, Dongsheng Z, editors, MEDINFO 2017: Precision Healthcare through Informatics - Proceedings of the 16th World Congress on Medical and Health Informatics. IOS Press BV. 2017. p. 999-1003. (Studies in Health Technology and Informatics). doi: 10.3233/978-1-61499-830-3-999

Arsoniadis, Elliot G. ; Skube, Steven J. ; Bjerke, Treva M. et al. / Assessing provider-generated free-text quality in EHR-Integrated Handoff Notes. MEDINFO 2017: Precision Healthcare through Informatics - Proceedings of the 16th World Congress on Medical and Health Informatics. editor / Adi V. Gundlapalli ; Jaulent Marie-Christine ; Zhao Dongsheng. IOS Press BV, 2017. pp. 999-1003 (Studies in Health Technology and Informatics).

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Assessing provider-generated free-text quality in EHR-Integrated Handoff Notes

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