Morrison, Zoe, Fernando, Bernard, Kalra, Dipak, Cresswell, Kathrin and Sheikh, Aziz (2013) National evaluation of the benefits and risks of greater structuring and coding of the electronic health record: exploratory qualitative investigation. Journal of the American Medical Informatics Association, 21 (3). pp. 492-500. ISSN 1067-5027 (Print), 1527-974X (Online) (doi:10.1136/amiajnl-2013-001666)

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Abstract

Objective:
We aimed to explore stakeholder views, attitudes, needs, and expectations regarding likely benefits and risks resulting from increased structuring and coding of clinical information within electronic health records (EHRs).

Materials and methods:
Qualitative investigation in primary and secondary care and research settings throughout the UK. Data were derived from interviews, expert discussion groups, observations, and relevant documents. Participants (n=70) included patients, healthcare professionals, health service commissioners, policy makers, managers, administrators, systems developers, researchers, and academics.

Results:
Four main themes arose from our data: variations in documentation practice; patient care benefits; secondary uses of information; and informing and involving patients. We observed a lack of guidelines, co-ordination, and dissemination of best practice relating to the design and use of information structures. While we identified immediate benefits for direct care and secondary analysis, many healthcare professionals did not see the relevance of structured and/or coded data to clinical practice. The potential for structured information to increase patient understanding of their diagnosis and treatment contrasted with concerns regarding the appropriateness of coded information for patients.

Conclusions:
The design and development of EHRs requires the capture of narrative information to reflect patient/clinician communication and computable data for administration and research purposes. Increased structuring and/or coding of EHRs therefore offers both benefits and risks. Documentation standards within clinical guidelines are likely to encourage comprehensive, accurate processing of data. As data structures may impact upon clinician/patient interactions, new models of documentation may be necessary if EHRs are to be read and authored by patients.

Item Type:	Article
Additional Information:	Open Access. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/
Uncontrolled Keywords:	Electronic Health Records, Electronic Patient Records, Data Structure, Clinical Coding, Patient Communication
Subjects:	R Medicine > R Medicine (General)
Faculty / School / Research Centre / Research Group:	Faculty of Business Faculty of Business > Department of Human Resources & Organisational Behaviour
Last Modified:	18 Sep 2019 08:49
URI:	http://gala.gre.ac.uk/id/eprint/21826

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