Structuring of electronic health records

Added May 5, 2020

Citation: Vuokko R, Mäkelä-Bengs P, Hyppönen H, et al. Impacts of structuring the electronic health record: Results of a systematic literature review from the perspective of secondary use of patient data. International Journal of Medical Informatics 2017; 97: 293-303

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What is this? The COVID-19 pandemic is placing a strain on healthcare services. Existing research on electronic health records (EHR) or (electronic medical records (EMR)) may provide information to help policy makers with this.

In this systematic review, the authors searched for research that evaluated the impacts of EHR structuring methods, with a focus on the use of patient data by secondary users (hospital administrators, information managers, developers of EHR and decision support systems, registry administrators, researchers, statisticians and healthcare service developers). They restricted their search to studies published between 1975 and 2010. They identified 85 studies that mostly evaluated EHR structuring methods at secondary or tertiary levels. More than half the articles (49) were from the USA, with others from Australia, Brazil, Canada, China, Europe, Japan and South Africa.

What was found: Data documented in structured patient records needs to be sufficiently complete, uniformly coded and documented in order to be reliable and interoperable for secondary use.

Most of the identified benefits of structured EHR data for secondary use purposes concentrated on information content and quality or on technical quality and reliability, particularly in the case of Natural Language Processing studies.

Whether structured EHR would result in higher quality care of patients is uncertain.

 

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