Medication changes are not always documented properly in physician notes or the electronic medical record
Research Activities, January 2010, No. 353
Physicians are accustomed to documenting patient care facts in their narrative notes, including medication changes. With the growth in electronic medical record (EMR) systems, however, more of this information is being entered into structured data fields. A new study finds that information on drug changes isn't always recorded in both places. Researchers looked at the documentation of medication intensification for high blood pressure in 5,634 patients with diabetes. Both physician notes (narrative) and EMR records (structured) were examined to see if physicians documented the start of a new antihypertensive medication or an increase in the dose of an existing medication.
A total of 18,185 medication changes were identified during the study period from 2000 to 2005. Physicians documented less than a third (30.9 percent) of these changes in both the narrative physician notes and the structured EMR data entry fields. However, the probability of a medication intensification being documented in both records increased 11 percent for each study year. This reflected the level of comfort experienced by physicians as they became more acquainted with the EMR system. Older physicians were less likely to document medication changes in both records, with the probability declining by 19 percent for each decade of provider age.
The researchers also uncovered a relationship between documentation of medication intensification and improvement in blood pressure readings. An increase of one medication intensification per month documented in either narrative or structured formats was associated with a 5-8 mm Hg decrease in systolic and a 1.5-4 mm Hg decrease in diastolic blood pressure. The study was supported in part by the Agency for Healthcare Research and Quality (HS17030).
See "Comparison of information content of structured and narrative text data sources on the example of medication intensification," by Alexander Turchin, M.D., Maria Shubina, D.Sc., Eugene Breydo, Ph.D. and others, in the May/June 2009 Journal of the American Medical Informatics Association 16(3), pp. 362-370.