Almost one third of ophthalmology patients' EHRs may not reflect the most accurate and current medication information, according to a study published in JAMA Ophthalmology.
Ann Arbor-based University of Michigan researchers analyzed medication data in EHRs of 53 patients treated in a tertiary care, referral academic medical center's ophthalmology department between July 2015 and August 2018. The patients had microbial keratitis, an infection of the cornea, and were treated until disease resolution.
Of the 247 medications identified, 23 percent of prescribed medications were different between the progress notes and the formal EHR-based medication history. Thirty-two percent of patients had at least one medication mismatch reported in their EHR, according to the report.
Reasons for the medication discrepancies include medications not prescribed through the EHR ordering system (43.9 percent), outside medications not recorded in the internal EHR medication list (40.4 percent) and medications that were prescribed through the EHR ordering system and in the formal list but not described in the clinical note (15.8 percent).
"This level of inconsistency is a red flag," Maria Woodward, MD, lead study author and assistant professor of ophthalmology at University of Michigan, said in a news release. "Patients who rely on the after-visit summary may be at risk for avoidable medication errors that may affect their healing or experience medication toxicity."
Study authors concluded that to improve accuracy of medication information for patients and researchers, EHR developers should create software solutions that aim to decrease clinical documentation burdens and make it easier to reconcile names and dosages of medications.