Comparing Patient-Reported Symptoms and Structured Clinician Documentation in Electronic Health Records
Read the abstract
Moderator
Joanna Abraham, PhD, FACMI, FAMIA
Washington University School of Medicine
Presenter
Victor M. Castro
Mass General Brigham and Northeastern University
Statement of Purpose
Real-world data (RWD) from electronic health records (EHRs) are increasingly used to understand health outcomes in diverse populations. However, much of this data relies on structured clinician documentation, which often reflects billing and administrative needs rather than the full spectrum of patient experiences. Patient-reported outcomes (PROMs), now systematically collected in many health systems, offer a complementary perspective that can capture symptoms underrepresented in structured codes.
This work demonstrates that patients self-report common symptoms such as joint pain, headaches, and sleep disturbances at far higher rates than clinicians document them, while conditions such as anxiety and depression are more often coded by clinicians. By quantifying the gaps and limited agreement between patient-reported and clinician-documented symptoms across more than 900,000 primary care visits, this study highlights both the risks of misclassification in RWD studies and the opportunities to integrate patient voices into clinical informatics. These findings advance the field by providing empirical evidence that PROMs can enrich EHR-based research, improve phenotype definitions, and ultimately support more patient-centered healthcare analytics.
Learning Objectives
- Recognize limitations of structured clinician documentation in EHRs and how reliance on billing-driven codes may misclassify patient symptoms in real-world data research.
- Evaluate the value of integrating patient-reported outcomes into EHR-based studies to improve accuracy and capture patient perspectives.
- Apply strategies to improve research and clinical workflows by considering PROMs as complementary data sources when defining phenotypes, conducting observational studies, or designing health system interventions.
Additional Information
The target audience for this activity includes physicians, nurses, other healthcare providers, and medical informaticians.
No commercial support was received for this activity.
Completion of this “Other Activity (Regularly Scheduled Series – RSS)” is demonstrated by participating in the live webinar or viewing the on-demand recording, engaging with presenters during the live session by submitting questions, and completing the evaluation survey at the conclusion of the course.
Learners may claim credit and download a certificate upon submission of the evaluation. Participation in additional resources and the course forum is encouraged but optional.
The American Medical Informatics Association is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
The American Medical Informatics Association designates this Other activity (Regularly Scheduled Series (RSS)) for a maximum of 12 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
The American Medical Informatics Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation.
- Nurse Planner (Content): Robin Austin, PhD, DNP, DC, RN, NI-BC, FAMIA, FAAN
- Approved Contact Hours: 12 CME/CNE
It is the policy of the American Medical Informatics Association (AMIA) to ensure that Continuing Medical Education (CME) activities are independent and free of commercial bias. To ensure educational content is objective, balanced, and guarantee content presented is in the best interest of its learners and the public, the AMIA requires that everyone in a position to control educational content disclose all financial relationships with ineligible companies within the prior 24 months. An ineligible company is one whose primary business is producing, marketing, selling, re-selling or distributing healthcare products used by or on patients. Examples can be found at accme.org.
In accordance with the ACCME Standards for Integrity and Independence in Accredited Continuing Education, AMIA has implemented mechanisms prior to the planning and implementation of this CME activity to identify and mitigate all relevant financial relationships for all individuals in a position to control the content of this CME activity.
In accordance with the ACCME Standards for Integrity and Independence in Accredited Continuing Education, AMIA has implemented mechanisms prior to planning and implementation of this CME activity to identify and mitigate all relevant financial relationships for all individuals in a position to control the content of this CME activity.
Faculty and planners who refuse to disclose any financial relationships with ineligible companies will be disqualified from participating in the educational activity.
For an individual with no relevant financial relationship(s), course participants must be informed that no conflicts of interest or financial relationship(s) exist.
Disclosures
Planning Committee
The planning committee and reviewers reported that they have no relevant financial relationship(s) with ineligible companies to disclose.
- Joanna Abraham, PhD, FACMI, FAMIA
- Jifan Gao, MS
- Frances Hsu, BS, MS
- Sonish Sivarajkumar
- Song Wang, MS
- Faisal Yaseen
Presenter
The following presenters have no relevant financial relationship(s) with ineligible companies to disclose.
AMIA Staff
The AMIA staff have no relevant financial relationship(s) with ineligible companies to disclose.
*All of the relevant financial relationships listed for these individuals have been mitigated.
