National evaluation of the benefits and risks of greater structuring and coding of the electronic health record

TY - JOUR

T1 - National evaluation of the benefits and risks of greater structuring and coding of the electronic health record

T2 - Exploratory qualitative investigation

AU - Morrison, Zoe

AU - Fernando, Bernard

AU - Kalra, Dipak

AU - Cresswell, Kathrin

AU - Sheikh, Aziz

N1 - 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/ Funding: This work was funded by the NHS CFH Evaluation Programme (NHS CFHEP 009). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NHS CFH Evaluation Programme or the Department of Health. AS is supported by a Harkness Health Policy and Practice Fellowship from The Commonwealth Fund. Acknowledgements: We gratefully acknowledge the advice on this research which has been provided by members of the Independent Project Steering Committee overseeing our program of work into the structuring and coding of the clinical record. Chaired by Professor Simon de Lusignan, this group also comprises Dr Nick Booth, Dr Stephen Kay, and Lee Priest. We are grateful to Professor Brian McKinstry, Dr Hilary Pinnock, and the reviewers for their constructive suggestions on an earlier draft of this manuscript.

PY - 2014/5

Y1 - 2014/5

N2 - 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.

AB - 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.

UR - http://www.scopus.com/inward/record.url?scp=84901848699&partnerID=8YFLogxK

U2 - 10.1136/amiajnl-2013-001666

DO - 10.1136/amiajnl-2013-001666

M3 - Article

VL - 21

SP - 492

EP - 500

JO - Journal of the American Medical Informatics Association

JF - Journal of the American Medical Informatics Association

SN - 1067-5027

IS - 3

ER -