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Free-text fields change the meaning of coded data

W R Hogan1, M M Wagner

  • 1Center for Biomedical Informatics University of Pittsburgh, USA.

Proceedings : a Conference of the American Medical Informatics Association. AMIA Fall Symposium
|January 1, 1996
PubMed
Summary
This summary is machine-generated.

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Free-text fields in electronic medical records (EMRs) offer flexibility but can alter coded data meaning. This study found supplemental free text frequently lowers data accuracy for medical decision-support systems.

Area of Science:

  • Medical Informatics
  • Clinical Data Management
  • Health Information Technology

Background:

  • Electronic medical records (EMRs) often combine coded fields with free-text fields to enhance data capture flexibility.
  • While free text can improve clinician acceptance and data completeness, its impact on data accuracy requires careful consideration.

Purpose of the Study:

  • To investigate how free-text entries in medication data affect the accuracy of coded information within an EMR.
  • To evaluate the consequences of supplemental free text on the performance of a medical decision-support system (MDSS).

Main Methods:

  • Analysis of free-text entries made by clinicians during medication data recording in an EMR system.
  • Assessment of the impact of these free-text entries on the interpretation and accuracy of associated coded data.

Related Experiment Videos

  • Evaluation of the effect on a specific medical decision-support system (MDSS).

    • Main Results:

    • Free-text entries were found to frequently alter the intended meaning of coded medication data.
    • This alteration in meaning led to a reduction in data accuracy for the EMR's medical decision-support system (MDSS).

    Conclusions:

    • Supplemental free-text fields in EMRs, while beneficial for flexibility, can significantly compromise the accuracy of coded data.
    • The findings highlight a critical challenge for health information technology systems relying on accurate coded data for clinical decision support.