Overcoming data challenges to measure whole-person health in electronic health records

Abstract: The allostatic load index (ALI) is a composite measure of whole-person health. Data from electronic health records (EHR) present a huge opportunity to operationalize the ALI in the learning health system, except they are prone to missingness and errors. Validation of EHR data (e.g., through chart reviews) can provide better-quality data, but realistically, only a subset of patients' data can be validated, and most protocols do not recover missing data. Using a representative sample of 1000 patients from the EHR at an extensive learning health system (100 of whom could be validated), we propose methods to design, conduct, and analyze statistically efficient and robust studies of the ALI and healthcare utilization. With semiparametric maximum likelihood estimation, we robustly incorporate all available data into statistical models. Using targeted design strategies, we examine ways to select the most informative patients for validation. Incorporating clinical expertise, we devise a novel validation protocol to promote the quality and completeness of EHR data. Validating the EHR data uncovered relatively low error rates and recovered some missing data. Through simulation studies based on preliminary data, residual sampling was identified as the most informative strategy for completing our validation study. Statistical models of partially validated data indicated higher odds of engaging in the healthcare system were associated with worse whole-person health (i.e., higher ALI), adjusting for age. Targeted validation with an enriched protocol allowed us to ensure the quality and promote the completeness of the EHR. Findings from our validation study were incorporated into analyses as we operationalize the ALI as a whole-person health measure intended to predict healthcare utilization in the academic learning health system.