Accuracy of the electronic health record’s problem list in describing multimorbidity in patients with heart failure in the emergency department

Brandon L. King; Michelle L. Meyer; Srihari V. Chari; Karen Hurka-Richardson; Thomas Bohrmann; Patricia P. Chang; Jo Ellen Rodgers; Jan Busby-Whitehead; Martin F. Casey

doi:10.1371/journal.pone.0279033

Peer Review History

Original SubmissionMarch 30, 2022
13 May 2022 Decision Letter - Fabrizio Pecoraro, Editor Transfer Alert This paper was transferred from another journal. As a result, its full editorial history (including decision letters, peer reviews and author responses) may not be present. PONE-D-22-09414Accuracy of the Electronic Health Record’s Problem List in Describing Multimorbidity in Patients with Heart Failure in the Emergency DepartmentPLOS ONE Dear Dr. Casey, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Jun 27 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Fabrizio Pecoraro Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information. If you are reporting a retrospective study of medical records or archived samples, please ensure that you have discussed whether all data were fully anonymized before you accessed them and/or whether the IRB or ethics committee waived the requirement for informed consent. If patients provided informed written consent to have data from their medical records used in research, please include this information. 3. Please update your submission to use the PLOS LaTeX template. The template and more information on our requirements for LaTeX submissions can be found at http://journals.plos.org/plosone/s/latex. 4. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section. 5. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability. Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. 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Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Partly Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Casey et al. present a study to evaluate a multimorbidity ‘problem list’ via electronic health records (EHRs) for patients with heart failure (HF) admitted in emergency departments (ED). The population sample was drawn from patients admitted in the ED of a southeastern US academic medical center. The inclusion criteria were determined on the basis of ICD-10 and demographics. An problem list across multiple disease domains was defined and multimorbidity was measured as gold standard via a 4-steps thorough chart review (plus additional materials if needed, e.g., echocardiography reports) performed by two trained persons and further checked by MD and nurse practitioner. The AHRQ Elixhauser (ICD-10) comorbidity score was calculated by manually reviewing ICD-10 codes. Domain based, and overall concordance indices for the cart review were calculated (i.e., PABAK, ICC), and then PPV and NPV of the gold standard with Elixhauser scores (three summary indices). Results show a large range of variability in both the concordance indices and the diagnostic accuracy when stratifying by domain. In particular, there was poor capture of obesity and hypertension. The authors conclude that the diagnostic accuracy of the EHR-based multimorbidity problem list for patients with HF in ED. Overall, the manuscript is well-written and well-structured, with balance among the presented sections. However, there are concerns about the study rationale/premise, and robustness of analysis for which the conclusive claims or the clinical relevance might be hampered, diminished. Methodological issues: 1. Study sample. First, ED/HF patients would possibly present as a selected population with comorbidity bias in one or more domains; the authors acknowledge that in part, but it may be a major driver. Second, the random sample was 200 over 1,130 eligible patients in the EHR data extraction. Even if chart review might have been too cumbersome for the whole sample, at least comparison with demographics and other descriptive statistics should have been made. 2. Most of EHR systems nowadays provide automated calculation of comorbidity index, usually the Charlson’s. The way in which the calculation is performed can vary, e.g., the time of lookback for finding a chronic condition, or the number of times a condition is diagnosed to confirm, and can be associated to a measurement error, population variance. The Elixhauser calculation presented here might have affected in the same way. The authors should have tried to consider a fully automated score provided by the EHR system. 3. The moderate PABAK and ICC in certain domains also indicates is substantial variability in clinical determinations, and this happens in parallel with the Elixhauser score determination, likely affecting the resulting diagnostic accuracy. 4. Given the continuous scales, a threshold analysis could have been useful (e.g., ROCs). Clinical significance issues: The work --as is-- stands as a mere exercise to compare imperfect, resource-intensive measures. The authors acknowledge the limitations. Yet, possibly, a predictive-based development based on these preliminary results could provide the translational relevance that does not emerge here. Reviewer #2: Thank you for a neat study. This would be improved by including: 1. The means of random chart selection. 2. Assessment of key demographics (which ought to be readily suitable for automated statistical count) between the sample and the full non-excluded population - such as age, gender, ethnicity. This would confirm that the sample was representative in practice. 3. Discussion of the hypothetical savings which could be obtained in ED time if applied as a routine practice - e.g. saved time per patient; patients per day. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: Yes:** Professor Emeritus Michael Rigby [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0279033.r001
Revision 1
5 Sep 2022 Author Response Reviewer #1: Casey et al. present a study to evaluate a multimorbidity ‘problem list’ via electronic health records (EHRs) for patients with heart failure (HF) admitted in emergency departments (ED). The population sample was drawn from patients admitted in the ED of a southeastern US academic medical center. The inclusion criteria were determined on the basis of ICD-10 and demographics. An problem list across multiple disease domains was defined and multimorbidity was measured as gold standard via a 4- steps thorough chart review (plus additional materials if needed, e.g., echocardiography reports) performed by two trained persons and further checked by MD and nurse practitioner. The AHRQ Elixhauser (ICD-10) comorbidity score was calculated by manually reviewing ICD-10 codes. Domain based, and overall concordance indices for the cart review were calculated (i.e., PABAK, ICC), and then PPV and NPV of the gold standard with Elixhauser scores (three summary indices). Results show a large range of variability in both the concordance indices and the diagnostic accuracy when stratifying by domain. In particular, there was poor capture of obesity and hypertension. The authors conclude that the diagnostic accuracy of the EHR-based multimorbidity problem list for patients with HF in ED. Overall, the manuscript is well-written and well-structured, with balance among the presented sections. However, there are concerns about the study rationale/premise, and robustness of analysis for which the conclusive claims or the clinical relevance might be hampered, diminished. AUTHORS Response: Thanks for the positive feedback on our writing. We recognize the limitations of the proposed methodology, specifically that 1.7 domains were not identified per patient when using the EHR-based problem list. Although the proposed methodology for measuring multimorbidity has clear limitations, the method does form the basis of a promising foundation which can be built upon by extracting additional data elements (e.g., lab values, radiographic findings) to improve overall accuracy. We have updated the manuscript text to acknowledge this feedback (see page 9-10), which we very much agree with. Methodological issues: 1. Study sample. First, ED/HF patients would possibly present as a selected population with comorbidity bias in one or more domains; the authors acknowledge that in part, but it may be a major driver. Second, the random sample was 200 over 1,130 eligible patients in the EHR data extraction. Even if chart review might have been too cumbersome for the whole sample, at least comparison with demographics and other descriptive statistics should have been made. AUTHORS Response: We have included a new supplemental table that compares the demographics of the 1,130 eligible patients to the 200 patients randomly selected for chart review. We believe the values are comparable across the two groups (reflecting that random selection of charts for review was performed correctly; see Supplemental Table 1). 2. Most of EHR systems nowadays provide automated calculation of comorbidity index, usually the Charlson’s. The way in which the calculation is performed can vary, e.g., the time of lookback for finding a chronic condition, or the number of times a condition is diagnosed to confirm, and can be associated to a measurement error, population variance. The Elixhauser calculation presented here might have affected in the same way. The authors should have tried to consider a fully automated score provided by the EHR system. AUTHORS Response: We have investigated whether our healthcare system’s EHR includes any measures of comorbidity such the Elixhauser or Charlson index. Unfortunately, our current EHR build does not include any measures of comorbidity. Thank you for this suggestion. 3. The moderate PABAK and ICC in certain domains also indicates is substantial variability in clinical determinations, and this happens in parallel with the Elixhauser score determination, likely affecting the resulting diagnostic accuracy. AUTHORS Response: We included a discussion on this topic in our limitation section (see page 10). Thank you for this suggestion. 4. Given the continuous scales, a threshold analysis could have been useful (e.g., ROCs). AUTHORS: We maximized study power by using continuous scales, rather than thresholds. Unfortunately, the idea of multimorbidity measurement as a standalone measurement is still relatively nascent. We are unaware of any consensus agreements on meaningful thresholds that could be used to guide an ROC analysis comparing domain count and Elixhauser index scores. We do appreciate this suggestion, but do not see viable approach to implementing a meaningful ROC analysis. Reviewer #2 Clinical significance issues: The work --as is-- stands as a mere exercise to compare imperfect, resource-intensive measures. The authors acknowledge the limitations. Yet, possibly, a predictive-based development based on these preliminary results could provide the translational relevance that does not emerge here. AUTHORS Response: See above. We have expanded some language in our manuscript to highlight use of additional structured data elements (such as, laboratory values, radiographic findings) and advanced methods (such as machine-line) which incorporate unstructured data in capturing the burden of multimorbidity (see page 10). Reviewer #2: Thank you for a neat study. This would be improved by including: 1. The means of random chart selection. AUTHORS Response: We have a included a description and citation on the random sequence generator used to select charts in our methods. Thank you for this suggestion. 2. Assessment of key demographics (which ought to be readily suitable for automated statistical count) between the sample and the full non-excluded population - such as age, gender, ethnicity. This would confirm that the sample was representative in practice. AUTHORS Response: See above commentary on inclusion of new Supplemental Table 1. 3. Discussion of the hypothetical savings which could be obtained in ED time if applied as a routine practice - e.g. saved time per patient; patients per day. AUTHORS Response: We have expanded on the implications for ED physicians (see page 9), though with the caveats that the EHR-problem list is not a perfect technique. We are not aware of any studies on the exact time ED physicians spend obtaining medical history per patient, and thus are unable to quantify a meaningful hypothetical savings. We do appreciate this suggestion. Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliation s.pdf AUTHORS Response: We have reviewed the guidelines and updated the body of text accordingly. 2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information. If you are reporting a retrospective study of medical records or archived samples, please ensure that you have discussed whether all data were fully anonymized before you accessed them and/or whether the IRB or ethics committee waived the requirement for informed consent. If patients provided informed written consent to have data from their medical records used in research, please include this information. AUTHORS Response: We have updated this section appropriately. 3. Please update your submission to use the PLOS LaTeX template. The template and more information on our requirements for LaTeX submissions can be found at http://journals.plos.org/plosone/s/latex. AUTHORS Response: We have reviewed the guidelines and updated the body of text accordingly. 4. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section. AUTHORS Response: We have updated this section appropriately. 5. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability. Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized. AUTHORS Response: We have created a deidentified dataset to be uploaded that will be uploaded to our supplement in accord with PlosOne’s policies. Some variables such as gender and race were removed due to internal policies to ensure protection of private health information. These variables can be made available upon author request. Attachments Attachment Submitted filename: Response to reviewers.pdf https://doi.org/10.1371/journal.pone.0279033.r002
28 Sep 2022 Decision Letter - Fabrizio Pecoraro, Editor PONE-D-22-09414R1Accuracy of the Electronic Health Record’s problem list in describing multimorbidity in patients with heart failure in the emergency departmentPLOS ONE Dear Dr. Casey, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. As reported by Reviewer 1, some additional efforts should be made to investigate some of the issues previously highlighted by him/her, in particular with the domain determination (e.g., with a design change to assess robustness) and with the diagnostic accuracy. I suggest to update the paper on the basis of the Reviewer 1's comments before resubmit it to PLOS ONE. Please submit your revised manuscript by Nov 12 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Fabrizio Pecoraro Academic Editor PLOS ONE Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: (No Response) Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Partly Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: I Don't Know ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The authors have provided reasonable responses to my comments. However, rather than addressing the limitations of their paper, they have merely acknowledged them. I think that some additional effort should be made to investigate some of the issues previously highlighted, in particular with the domain determination (e.g., with a design change to assess robustness) and with the diagnostic accuracy. Computational phenotyping is an iterative process, but at the moment the paper still falls shorts of its premise and objective. Nonetheless, if the authors elaborate more on the domain and diagnostic performance, the manuscript could be published. Reviewer #2: Thank you for addressing previous reviewer feedback, and providing a suitably improved and clearer manuscript. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0279033.r003
Revision 2
2 Nov 2022 Author Response As reported by Reviewer 1, some additional efforts should be made to investigate some of the issues previously highlighted by him/her, in particular with the domain determination (e.g., with a design change to assess robustness) and with the diagnostic accuracy. I suggest to update the paper on the basis of the Reviewer 1's comments before resubmit it to PLOS ONE. AUTHORS: We have incorporated a ROC curve analyses into our manuscript (pg 6, 9). Thank you for this suggestion as we believe it has made our manuscript more complete. Attachments Attachment Submitted filename: Response to reviewers.pdf https://doi.org/10.1371/journal.pone.0279033.r004
29 Nov 2022 Decision Letter - Fabrizio Pecoraro, Editor Accuracy of the Electronic Health Record’s problem list in describing multimorbidity in patients with heart failure in the emergency department PONE-D-22-09414R2 Dear Dr. Casey, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Fabrizio Pecoraro Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: No additional comments. No additional comments. No additional comments. No additional comments. No additional comments. Reviewer #2: The additional material enhances an already acceptable paper. Thank you for your careful considerations. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No ******** https://doi.org/10.1371/journal.pone.0279033.r005
Formally Accepted
2 Dec 2022 Acceptance Letter - Fabrizio Pecoraro, Editor PONE-D-22-09414R2 Accuracy of the electronic health record’s problem list in describing multimorbidity in patients with heart failure in the emergency department Dear Dr. Casey: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Fabrizio Pecoraro Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0279033.r006

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .