Given the tremendous volume of data used to document patient care and conditions, painting a comprehensive picture of a patient’s health should be fairly easy. But accessing a true digital twin in the electronic health record (EHR) isn’t a simple task.
Although clinical data is abundant, it is also complex, frequently unstructured, and riddled with gaps and inconsistencies. (As a result, analytics and insights grounded in this data are also inevitably flawed).
Many factors contribute to the distortion of our digital reflection in the patient chart. Among them are the prevalence of data siloes, the inaccessibility of certain types of data, and variations in clinical terminology. The excerpt below, from the IMO Health insight brief, Bridging reality and medical records: Data quality and the elusive digital twin, explores some of the challenges that arise from inconsistent terminology use within the EHR.
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INSIGHT BRIEF
Bridging reality and medical records:
Data quality and the elusive digital twin
Variations in terminology
When documenting patient conditions in the electronic health record (EHR), clinicians use the words they’re most comfortable with, whether it’s short forms, acronyms, slang, or more formal phrases. For example, one physician may say essential hypertension, another primary hypertension, while yet another may write HTN. This practice introduces a great deal of variability into the patient record if these synonyms aren’t harmonized to a single, standard term – which is then precisely mapped to standard codes for billing and reporting activities.
In the absence of a universal term, diagnosis data can be misinterpreted, omitted, or lost in translation as it moves from one provider to the next or through data lakes and health information exchanges (HIEs) . While this may
result in lost reimbursement for a provider, the patient’s situation is more dire. An incomplete digital twin is a flawed representation of a patient’s health and using that data can contribute to sub-optimal care – or the absence of care altogether.
