Electronic health record reviews to measure diagnostic uncertainty in primary care.
Viraj BhiseSuja S RajanDean F SittigViralkumar VaghaniRobert O MorganArushi KhannaHardeep SinghPublished in: Journal of evaluation in clinical practice (2018)
While current diagnosis coding mechanisms (ICD-9 and ICD-10) are unable to capture uncertainty, our study finds that review of EHR documentation can help identify diagnostic uncertainty with moderate reliability. Better measurement and understanding of diagnostic uncertainty could help inform strategies to improve the safety and efficiency of diagnosis.