A review of the empirical evidence of the value of structuring and coding of clinical information within electronic health records for direct patient care
<p><strong>Background </strong>The case has historically been presented that structured and/or coded electronic health records (EHRs) benefit direct patient care, but the evidence base for this is not well documented.</p><p><strong>Methods</strong> We search...
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| Format: | Article |
| Language: | English |
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BCS, The Chartered Institute for IT
2013-05-01
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| Series: | Journal of Innovation in Health Informatics |
| Subjects: | |
| Online Access: | http://hijournal.bcs.org/index.php/jhi/article/view/22 |
| _version_ | 1819195308731531264 |
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| author | Dipak Kalra Bernard Fernando Zoe Morrison Aziz Sheikh |
| author_facet | Dipak Kalra Bernard Fernando Zoe Morrison Aziz Sheikh |
| author_sort | Dipak Kalra |
| collection | DOAJ |
| description | <p><strong>Background </strong>The case has historically been presented that structured and/or coded electronic health records (EHRs) benefit direct patient care, but the evidence base for this is not well documented.</p><p><strong>Methods</strong> We searched for evidence of direct patient care value from the use of structured and/or coded information within EHRs. We interrogated nine international databases from 1990 to 2011. Value was defined using the Institute of Medicine’s six areas for improvement for healthcare systems: effectiveness, safety, patient-centredness, timeliness, efficiency and equitability. We included studies satisfying the Cochrane Effective Practice and Organisation of Care (EPOC) group criteria.</p><p><strong>Results</strong> Of 5016 potentially eligible papers, 13 studies satisfied our criteria: 10 focused on effectiveness, with eight demonstrating potential for improved proxy and actual clinical outcomes if a structured and/or coded EHR was combined with alerting or advisory systems in a focused clinical domain. Three studies demonstrated improvement in safety outcomes. No studies were found reporting value in relation to patient-centredness, timeliness, efficiency or equitability.</p><p><strong>Conclusions</strong> We conclude that, to date, there has been patchy effort to investigate empirically the value from structuring and coding EHRs for direct patient care. Future investments in structuring and coding of EHRs should be informed by robust evidence as to the clinical scenarios in which patient care benefits may be realised.</p> |
| first_indexed | 2024-12-23T02:10:42Z |
| format | Article |
| id | doaj.art-0f76d41a789f4414a31d80950cb01f65 |
| institution | Directory Open Access Journal |
| issn | 2058-4555 2058-4563 |
| language | English |
| last_indexed | 2024-12-23T02:10:42Z |
| publishDate | 2013-05-01 |
| publisher | BCS, The Chartered Institute for IT |
| record_format | Article |
| series | Journal of Innovation in Health Informatics |
| spelling | doaj.art-0f76d41a789f4414a31d80950cb01f652022-12-21T18:03:47ZengBCS, The Chartered Institute for ITJournal of Innovation in Health Informatics2058-45552058-45632013-05-0120317118010.14236/jhi.v20i3.2213A review of the empirical evidence of the value of structuring and coding of clinical information within electronic health records for direct patient careDipak Kalra0Bernard Fernando1Zoe Morrison2Aziz Sheikh3Clinical Professor of Health Informatics, Centre for Health Informatics and Multiprofessional Education, University College London, UKClinical Research Fellow, eHealth Research Group, Centre for Population Health Sciences, The University of Edinburgh, UKResearch Associate, eHealth Research Group, Centre for Population Health Sciences, The University of Edinburgh, UKProfessor of Primary Care Research & Development, eHealth Research Group, Centre for Population Health Sciences, The University of Edinburgh, UK<p><strong>Background </strong>The case has historically been presented that structured and/or coded electronic health records (EHRs) benefit direct patient care, but the evidence base for this is not well documented.</p><p><strong>Methods</strong> We searched for evidence of direct patient care value from the use of structured and/or coded information within EHRs. We interrogated nine international databases from 1990 to 2011. Value was defined using the Institute of Medicine’s six areas for improvement for healthcare systems: effectiveness, safety, patient-centredness, timeliness, efficiency and equitability. We included studies satisfying the Cochrane Effective Practice and Organisation of Care (EPOC) group criteria.</p><p><strong>Results</strong> Of 5016 potentially eligible papers, 13 studies satisfied our criteria: 10 focused on effectiveness, with eight demonstrating potential for improved proxy and actual clinical outcomes if a structured and/or coded EHR was combined with alerting or advisory systems in a focused clinical domain. Three studies demonstrated improvement in safety outcomes. No studies were found reporting value in relation to patient-centredness, timeliness, efficiency or equitability.</p><p><strong>Conclusions</strong> We conclude that, to date, there has been patchy effort to investigate empirically the value from structuring and coding EHRs for direct patient care. Future investments in structuring and coding of EHRs should be informed by robust evidence as to the clinical scenarios in which patient care benefits may be realised.</p>http://hijournal.bcs.org/index.php/jhi/article/view/22clinical codingclinical outcomeselectronic health recordshealth information technologystructured data entry |
| spellingShingle | Dipak Kalra Bernard Fernando Zoe Morrison Aziz Sheikh A review of the empirical evidence of the value of structuring and coding of clinical information within electronic health records for direct patient care Journal of Innovation in Health Informatics clinical coding clinical outcomes electronic health records health information technology structured data entry |
| title | A review of the empirical evidence of the value of structuring and coding of clinical information within electronic health records for direct patient care |
| title_full | A review of the empirical evidence of the value of structuring and coding of clinical information within electronic health records for direct patient care |
| title_fullStr | A review of the empirical evidence of the value of structuring and coding of clinical information within electronic health records for direct patient care |
| title_full_unstemmed | A review of the empirical evidence of the value of structuring and coding of clinical information within electronic health records for direct patient care |
| title_short | A review of the empirical evidence of the value of structuring and coding of clinical information within electronic health records for direct patient care |
| title_sort | review of the empirical evidence of the value of structuring and coding of clinical information within electronic health records for direct patient care |
| topic | clinical coding clinical outcomes electronic health records health information technology structured data entry |
| url | http://hijournal.bcs.org/index.php/jhi/article/view/22 |
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