Best Practices for Publishing Your Medical Record Review Study: Harnessing Electronic Health Record Data (Research Committee- and Evidence-Based Healthcare & Implementation Interest Group-Sponsored)

Retrospective chart reviews are a common research design, but they carry potential pitfalls that can affect the quality of findings. When conducted rigorously, however, these studies offer valuable insights. As journal editors and peer reviewers, we have identified the need for researchers to understand best practices for executing high-quality medical record review studies to improve publishability. This session will outline key principles of effective design and execution, emphasizing the importance of clear study design (cross-sectional, case-control, cohort), reducing bias, and ensuring objective, standardized processes. We will discuss protocols for data review and measures like inter-rater reliability to enhance study validity.

Learning Objectives:

Upon completion of this session, participants should be able to:
  • Describe the pros and cons of performing a medical records review study.
  • Describe the steps in creating a medical records review study.
  • Identify strategies to minimize bias in performing a medical records review study.
  • Review three medical record review studies and decide how they can be improved.

Presenters:

  • Dan Mayer, MD
  • Richelle J. Cooper, MD, MSHS
  • Elizabeth M. Goldberg, MD, ScM
  • James H. Paxton, MD, MBA
  • Peter C. Hou, MD
  • Michael Gottlieb, MD
  • Andrew C. Meltzer, MD
Authors
  • Picture1

    Dan Mayer, MD

    Albany Medical College

    I have practiced as an Emergency Medicine physician for the past 43 years. I have been teaching for the past 37 years and practicing clinical Emergency Medicine for 35 years in a variety of hospital settings including academic urban emergency departments and rural community hospital emergency departments. I was an attending Emergency Medicine physician at Albany Medical Center Hospital from 1987 until my retirement in 2014. I also taught evidence-based medicine, medical decision-making and Emergency Medicine at Albany Medical College. I have taught medical students, other health science students, residents and attending physicians. Currently I teach EBM to dental residents through NYU Dental School. I have been board certified in Emergency Medicine since 1984. I am currently retired from active clinical practice and still active in publishing medical research in Emergency Medicine and teaching EBM to dental residents. I am an Associate Editor for the Western Journal of Emergency Medicine and JACEP Open. I was an associate editor for MedEdPORTAL for 12 years and still perform reviews for them. I have been an outstanding peer-reviewer for Academic Medicine, JACEP Open, Western Journal of Emergency Medicine, Academic Emergency Medicine, MedEdPORTAL, and Annals of Emergency Medicine. I have given many presentations on EBM, Team Based Learning, Diagnostic error, Peer review, and critical appraisal at many national and international meetings.

  • Richelle J. Cooper, MD, MSHS

    David Geffen UCLA School of Medicine

    Dr. Cooper is Professor of Emergency Medicine at the UCLA School of Medicine, and VIce Chair of Research for the UCLA Department of Emergency Medicine, at the UCLA Ronald Reagan Medical Center. Dr Cooper has been one of the methodology and statistics editors at Annals of Emergency Medicine since 2000, and is Executive Deputy Editor of Annals of Emergency Medicine. She has conducted research on, and lectured on multiple topics related to peer-review. Her research interests include the science of peer review and methodology, gender and healthcare disparities, social emergency medicine, and overuse and low value care. She serves on the American College of Emergency Physicians Research Committee.
  • LizGoldberg---12 - Liz Goldberg, MD

    Elizabeth M. Goldberg, MD, ScM

    University of Colorado, Denver

    Dr. Liz Goldberg is a practicing emergency physician and Associate Professor of Emergency Medicine at the University of Colorado School of Medicine. After her residency, she completed a post-doctoral research fellowship in gerontology and epidemiology at Brown University. Dr. Goldberg is the recipient of the prestigious Paul B. Beeson Career Development Award from the National Institute on Aging which funds a fall prevention trial using the Apple Watch to track cognition and fitness. Her research focus is creating effective interventions to improve emergency care for geriatric patients, and using digital tools to help older adults age in place. Dr. Goldberg is the past President of the Academy for Geriatric Emergency Medicine for the Society of Academic Emergency Medicine. In this capacity she led the research and education efforts of over 300 academic clinicians to improve geriatric emergency care in the US.

  • James H. Paxton, MD, MBA

    Associate Professor and Director of Clinical Research

    Detroit Receiving Hospital / Wayne State University Department of Emergency Medicine

    James H. Paxton, MD, MBA, is an associate professor and the Director of Clinical Research for Detroit Receiving Hospital / Wayne State University (WSU) Department of Emergency Medicine, and previously served as Chairman of the WSU MP2 Institutional Review Board (2015-2020). He is a senior member of multiple national emergency medicine research committees, and recently served as Chairman of the SAEM research committee (2021-2024). Dr. Paxton received both his MD and MBA from the University of Cincinnati and completed EM residency training at Henry Ford Hospital. He has been core academic faculty for the EM residencies at both Sinai-Grace Hospital and Detroit Receiving Hospital since 2011, and has mentored hundreds of medical students and residents at WSU during that time. He is an active clinical researcher and has served as PI for dozens of industry- and publicly-funded trials.

  • Peter C. Hou, MD

    Assistant Professor, Emergency Medicine

    Brigham and Women's Hospital

    Peter Hou, MD, is an assistant professor of emergency medicine (EM) at Brigham and Women's Hospital. He is dual-boarded in EM and critical care medicine, practicing in both the emergency department (ED) and intensive care unit (ICU). His clinical research interests include sepsis, acute respiratory distress syndrome, COVID-19, and quality improvement processes focused on the care of patients being admitted from the ED to the ICU. He was site-PI for the Protocolized Care for Early Septic Shock (ProCESS) Trial and multiple NIH-sponsored ProCESS ancillary studies evaluating the microcirculation and long-term outcomes of acute kidney injury and host immune response. He currently serves as Co-Lead for the Acute Lung Injury of New England Clinical Center, is a Steering Committee member for the NIH-sponsored Prevention and Early Treatment of Acute Lung Injury network, and the site-PI for the PETAL network trials.
  • Michael Gottlieb, MD

    Michael Gottlieb, MD

    Rush University Medical Center

    Michael Gottlieb, MD is the Vice Chair of Research and Director of the Emergency Ultrasound Division at Rush University Medical Center. He is Past-Chair of the ACEP Ultrasound Section and Past-Chair of the AAEM Ultrasound Section. He has authored over 500 peer-reviewed publications and is an Editor for Academic Medicine, The Annals of Emergency Medicine, The Western Journal of Emergency Medicine, The American Journal of Emergency Medicine, and Academic Emergency Medicine Education and Training, as well as the Social Media Editor for Academic Emergency Medicine. He is Past-Chair of the CORD Academy for Scholarship, Past-Chair of the SAEM Education Summit, Past-Chair of the CORD Education Committee, Past-Chair of the CORD Best Practices Subcommittee, and a nationally-recognized speaker and educator. His academic interests include medical education, ultrasound, infectious diseases, heart failure, and diversity, equity, and inclusion.

  • Andrew C. Meltzer, MD, MS

    George Washington University School of Medicine and Health Sciences

    Andrew C. Meltzer, MD MS FACEP is a Professor of Emergency Medicine and the Chief of the Clinical Research Section at the George Washington University School of Medicine. Dr. Meltzer completed his MD at SUNY Downstate, residency in Emergency Medicine at the University of Maryland and R Adams Cowley Shock Trauma Center, and his fellowship in Clinical Research at the University of Maryland. He is a Fellow of the American College of Emergency Physicians (ACEP) and member of the ACEP Clinical Policies Committee and the Society of Academic Emergency Medicine (SAEM) Research Committee. He was an author of the GRACE-2 Guidelines for Abdominal Pan and served as a member of the External Oversight Board for the SIREN research network. As part of an international team, he developed guidelines for the acute management of gastrointestinal bleeding. He was the principal investigator on the NIH-funded multi-center randomized control trial on medical expulsive therapy for renal colic. In addition, he was the PI on a multi-center trial examining novel way to diagnose gastrointestinal hemorrhage, the site PI on the CDC Recover grant, and the overall PI for the HYPERACT trial examining acute management of patients with respiratory distress. He has experience working with two successful technology companies as a chief medical officer. As of this writing, Dr. Meltzer had over 60 peer-reviewed authorships indexed in PubMed with over 1500 citations.

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