National evaluation of the benefits and risks of greater structuring and coding of the electronic health record: Exploratory qualitative investigation

Zoe Morrison*, Bernard Fernando, Dipak Kalra, Kathrin Cresswell, Aziz Sheikh

*Corresponding author for this work

Research output: Contribution to journalArticle

18 Citations (Scopus)
4 Downloads (Pure)

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.

Original languageEnglish
Pages (from-to)492-500
Number of pages9
JournalJournal of the American Medical Informatics Association
Volume21
Issue number3
Early online date1 Nov 2013
DOIs
Publication statusPublished - May 2014

    Fingerprint

ASJC Scopus subject areas

  • Health Informatics
  • Medicine(all)

Cite this