Variation in Laboratory Test Naming Conventions in EHRs Within and Between Hospitals: A Nationwide Longitudinal Study

Electronic health record (EHR) systems provide vast amounts of clinically rich data that can, in principle, be used in research and evaluation activities to improve patient care and outcomes. However, these data are typically organized to meet the diverse exigencies of ongoing clinical work and are not easy to use for research and evaluation purposes. EHR data are often recorded in the form of unstructured text fields, which require programming and clinical expertise to clean and classify the data before analysis. Failing to capture results may threaten (1) reliable performance measurement that requires all relevant values for risk adjustment; (2) clinical decision support based on laboratory values; and (3) the “big data” agenda that seeks to use laboratory values to discover new patterns of pathophysiology.