Medical Concept Intersection between Outside Medical Records and Consultant Notes - A Case Study in Transferred Cardiovascular Patients

摘要

One of the promises of "meaningful use" of Electronic Health Records (EHRs) is to facilitate digital information exchange between healthcare providers through continuity of care documents. Despite such promise, outside medical records (OMRs) of referral patients including clinical notes, lab test results or diagnostic test reports are frequently provided through fax or print out. Moreover, it is not clear how much information in those OMRs is utilized when providing care at the early stage. In this study, we collected clinical concepts automatically from OMRs through optical character recognition (OCR) technology and then performed a quantitative analysis of concepts presented in OMRs and concepts captured in clinical notes at Mayo Clinic. We also investigated information from OMRs not captured in initial consultant notes but presented over subsequent consultant notes. We identified 12.93% of concepts from OMRs were identified in clinical documents within three months. Among those overlapping concepts, 26.74% of them were not captured in initial consultant notes. Our study presents that clinical information from OMRs is important for patient care. Also, the delayed presence of information in clinical notes may indicate important information from OMRs is not fully utilized earlier in the care.