ArticleInternational journal of medical informatics2021
Data gaps in electronic health record (EHR) systems: An audit of problem list completeness during the COVID-19 pandemic.
Article in International journal of medical informatics, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 30 papers, 1 of them a synthesis that pooled it.
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Who cites it
30 citing papers in PubMed, 1 synthesis or guideline pooled it, 59 citations in OpenAlex.
- Which Electronic Health Record System Should We Use? A Systematic Review.Medical principles and practice : international journal of the Kuwait University, Health Science Centre · 2022Pooled it
- Depression as a Disease of White Matter Network Disruption: Learning From Multiple Sclerosis.Biological psychiatry · 2026Review
- Current state of electronic problems lists in primary care: a rapid scoping review.Family practice · 2026Article
- Graph augmented transformers improve chemotherapy toxicity symptom extraction from clinical notes.Nature communications · 2026Article
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- Clinical evaluation of MiADE: a natural language processing system for assisting structured diagnosis recording at the point of care.BMJ health & care informatics · 2026Article
- Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors.Diagnostics (Basel, Switzerland) · 2026Review
- From Billing Codes to Breakthroughs: Filtering Signal From Noise in Electronic Medical Records-Based Research.The Journal of neuropsychiatry and clinical neurosciences · 2026Article
- Dashboards to Improve Extractability of Cardiovascular Indicators in a Learning Health Care System: Mixed Methods Study.Journal of medical Internet research · 2025Article
- Design and implementation of a natural language processing system at the point of care: MiADE (medical information AI data extractor).BMC medical informatics and decision making · 2025Article
- Article
- Optimizing Documentation Integrity of Ophthalmic Diagnostic Test Interpretation through Electronic Health Record Clinical Decision Support.Applied clinical informatics · 2025Article
- Evaluation of Diagnostic Recommendations Embedded in Medication Alerts: Prospective Single-Arm Interventional Study.Journal of medical Internet research · 2025Article
- Guidelines to practice in hospitals at home: safe and effective continuous infusion pumps substantially increased penicillin use in erysipelas treatment.European journal of public health · 2024Article
- Evaluation of SNOMED CT Grouper Accuracy and Coverage in Organizing the Electronic Health Record Problem List by Clinical System: Observational Study.JMIR medical informatics · 2024Article
- Clinical Information Extraction with Large Language Models: A Case Study on Organ Procurement.AMIA ... Annual Symposium proceedings. AMIA Symposium · 2024Article
- Exploring the impact of missingness on racial disparities in predictive performance of a machine learning model for emergency department triage.JAMIA open · 2023Article
- New Horizons in artificial intelligence in the healthcare of older people.Age and ageing · 2023Article
- Limitations in the use of automated mental status detection for clinical decision support.International journal of medical informatics · 2023Article
- Clinical encounter heterogeneity and methods for resolving in networked EHR data: a study from N3C and RECOVER programs.Journal of the American Medical Informatics Association : JAMIA · 2023Article
Corrections and comments
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Authors and funding
3 authors at 2 institutions in 1 country.
Funding
No grant is acknowledged in the PubMed record.
Abstract
objectiveTo evaluate the completeness of diagnosis recording in problem lists in a hospital electronic health record (EHR) system during the COVID-19 pandemic.
designRetrospective chart review with manual review of free text electronic case notes.
settingMajor teaching hospital trust in London, one year after the launch of a comprehensive EHR system (Epic), during the first peak of the COVID-19 pandemic in the UK.
participants516 patients with suspected or confirmed COVID-19.
main outcome measuresPercentage of diagnoses already included in the structured problem list.
resultsPrior to review, these patients had a combined total of 2841 diagnoses recorded in their EHR problem lists. 1722 additional diagnoses were identified, increasing the mean number of recorded problems per patient from 5.51 to 8.84. The overall percentage of diagnoses originally included in the problem list was 62.3% (2841 / 4563, 95% confidence interval 60.8%, 63.7%).
conclusionsDiagnoses and other clinical information stored in a structured way in electronic health records is extremely useful for supporting clinical decisions, improving patient care and enabling better research. However, recording of medical diagnoses on the structured problem list for inpatients is incomplete, with almost 40% of important diagnoses mentioned only in the free text notes.
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