Using EHR Data to Examine Functional Recovery in Adults with Acquired Brain Injury

Research Objectives: To describe potential quality issues with rehabilitation data extracted from electronic health records (EHR) and approaches to data cleaning and management.

Design: Secondary analysis of EHR and billing data. Data included demographic, diagnostic, functional assessment at admission and discharge, time billed, and CPT codes for rehabilitation services.

Setting: Inpatient rehabilitation service at a large, urban academic hospital

Participants: Adults with acquired brain injury (n=799) admitted between 2011 and 2016

Interventions: N/A

Main Outcome Measures: Mobility and self-care function at discharge

Results: Demographic, diagnostic, functional measures, and billing data were obtained for the initial inpatient rehabilitation discharges for 799 adults with acquired brain injury from 2011-2016. Demographic, diagnostic, and functional data had been pre-cleaned during initial extraction procedure. Minimal missing or erroneous entries were identified in these data; 100% of the sample had complete FIM data for both admission and discharge. Billing data presented the greatest variability. Specifically, some billing entries included both rehabilitation units billed (e.g., 8-22 minutes) and actual minutes of treatment (e.g, 15 minutes), whereas others included only units billed. Treatment minutes were not required to be recorded in all years of data. Because units billed was a required entry, it was the more reliable measure of service delivery. All entries with rehabilitation units billed had valid CPT code descriptors. Thus, it was necessary to understand data entry processes and how they had changed over time to interpret raw data about service delivery and develop a coding approach that maximized reliability.

Conclusions: EHR may provide useful data for large observational studies of rehabilitation processes and outcomes. It is essential to have team members who are familiar with institution-specific front-end documentation and billing procedures. Challenges, opportunities, and strategies to address data accuracy will be discussed.

Author(s) Disclosures: The authors have nothing to disclose. The views expressed in this presentation are those of the authors and do not necessarily reflect the official policy or position of the Department of Veterans Affairs or the United States Government.