Benefits and risks of structuring and/or coding the presenting patient history in the electronic health record: Systematic review

BMJ Quality and Safety

Volumn 21, Issue 4, 2012, Pages 337-346

  Fernando, Bernard ^a   Kalra, Dipak ^b   Morrison, Zoe ^a   Byrne, Emma ^a   Sheikh, Aziz ^a  

^a UNIVERSITY OF EDINBURGH   (United Kingdom)

^b UNIVERSITY COLLEGE LONDON   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

CAREGIVER; DECISION SUPPORT SYSTEM; DOCUMENTATION; ELECTRONIC MEDICAL RECORD; HEALTH CARE POLICY; HEALTH STATUS; HUMAN; MEDICAL DECISION MAKING; MEDICAL HISTORY; MEDICAL INFORMATION SYSTEM; PATIENT CARE; REVIEW; SYSTEMATIC REVIEW;

CLINICAL CODING; ELECTRONIC HEALTH RECORDS; HUMANS; INFORMATION STORAGE AND RETRIEVAL; MEDICAL HISTORY TAKING; RISK ASSESSMENT;

EID: 84858747714     PISSN: 20445415     EISSN: None     Source Type: Journal    
DOI: 10.1136/bmjqs-2011-000450     Document Type: Review

References (53)

1. Catwell L, Sheikh A. Evaluating eHealth interventions: the need for continuous systemic evaluation. PLoS Med 2009;6:1-6.
2. Morrison Z, Robertson A, Cresswell K, et al. Understanding contrasting approaches to nationwide implementations of electronic health record systems: England, the USA and Australia. J Hlthcare Eng 2011;2:25-42.
3. Robertson A, Cresswell K, Takian A, et al. Implementation and adoption of nationwide electronic health records in secondary care in England: qualitative analysis of interim results from a prospective national evaluation. BMJ 2010;341:c4564.
4. Greenhalgh T, Stramer K, Bratan T, et al. Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case study. BMJ 2010;340:c3111.
5. Jha A, DesRoches C, Campbell E, et al. Use of electronic health records in U.S. hospitals. N Engl J Med 2009;360:1628-38.
6. Vacquerizo C. Final Definition of Functional Service Requirements - Patient Summary. Project Report D3.2.2., European Commission partially funded large scale pilot on Smart Open Services for European Patients (The epSOS Project). European Commission, 2010. http://www.epsos.eu/home/download-area/ deliverables.html
7. Kalra D, Blobel B. Semantic interoperability of EHR systems. In: Bos L, Blobel B, eds. Medical and Care Compunetics 4. Studies in Health Technology and Informatics 127. Amsterdam: IOS Press, 2007:231-45.
8. Thiru K, Hassey A, Sullivan F. Systematic review of scope and quality of electronic patient record data in primary care. BMJ 2003;326:1070.
9. Van Ginneken AM. Modelling domain-knowledge: a step toward intelligent data management. Methods Inf Med 1993;32:270-1. (Pubitemid 24244343)
10. Kay S, Purves IN. Medical records and other stories: a narratological framework. Methods Inf Med 1996;35:72-87. (Pubitemid 26241149)
11. Hurwitz B. Time, a narrative organiser of events and experience. Br J Gen Pract 2002;52:344-7. (Pubitemid 35021420)
12. Carpenter I. A Clinician's Guide to Record Standards-Part 2: Standards for the Structure and Content of Medical Records and Communications When Patients Are Admitted to Hospital. London: Academy of Medical Royal Colleges and the Royal College of Physicians, 2008.
13. UK Department of Health. Liberating the NHS: An Information Revolution-Consultation Document. Department of Health, 2010. http://ww.dh.gov/uk/liberatingthenhs (accessed 9 May 2011).
14. Blumenthal D, Tavenner M. The 'meaningful use' regulation for electronic health records. N Engl J Med 2010;363:501-4.
15. Stroetman V, Kalra D, Lewalle P, et al. Semantic Interoperability for Better Health and Safer Healthcare. The European Commission, 2009. doi:10.2759/38514. http://ec.europa.eu/information-society/ activities/health/ docs/publications/2009/2009semantic-health-report.pdf (accessed 9 May 2011).
16. Kalra D, Musen M, Smith B, et al. ARGOS policy brief on semantic interoperability. Stud Health Technology Inform 2011;170:1-15.
17. Bingham P, Lilford RJ, Chard T. Strengths and weaknesses of direct patient interviewing by a microcomputer system in specialist gynaecological practice. Eur J Obstet Gynaecol Reprod Biol 1984;18:43-56. (Pubitemid 14003734)
18. Teasdale S, Bates D, Kmetik K, et al. Secondary uses of clinical data in primary care. Inform Prim Care 2007;15:157-66. (Pubitemid 350148593)
19. Marcy TW, Kaplan B, Connolly SW, et al. Developing a decision support system for tobacco use counselling using primary care physicians. Inform Prim Care 2008;16:101-9.
20. Lilford RJ, Brown CA, Nicholl J. Use of process measures to monitor the quality of clinical practice. BMJ 2007;335:648-50. (Pubitemid 47548455)
21. Disse K. Microsoft health patient journey demonstrator. Inform Prim Care 2008;16:297-302.
22. Blumenthal D. Launching HITECH. N Engl J Med 2010;362:382-5.
23. Horsky J, Kaufman DR, Oppenheim MI, et al. A framework for analyzing the cognitive complexity of computer-assisted clinical ordering. J Biomed Inform 2003;36:4-22. (Pubitemid 37206387)
24. Tai TW, Anandarajah S, Dhoul N, et al. Variation in clinical coding lists in UK general practice: a barrier to consistent data entry? Inform Prim Care 2007;15:143-50. (Pubitemid 350148591)
25. Van Vleck TT, Wilcox A, Stetson PD, et al. Content and structure of clinical problem lists: a corpus analysis. AMIA Annu Symp Proc 2008;6:753-7.
26. Sager N, Lyman M, Bucknall C, et al. Natural language processing and the representation of clinical data. J Am Med Inform Assoc 1994;1:142-60.
27. Brown SH, Elkin PL, Rosenbloom ST, et al. eQuality for all: extending automated quality measurement of free text clinical narratives. AMIA Annu Symp Proc 2008;6:71-5.
28. Jagannathan V, Mullett CJ, Arbogast JG, et al. Assessment of commercial NLP engines for medication information extraction from dictated clinical notes. Int J Med Inform 2009;78:284-91.
29. Byrne E, Fernando B, Kalra D, et al. The benefits and risks of structuring and coding of patient histories in the electronic clinical record: protocol for a systematic review. Inform Prim Care 2011;18:197-203.
30. Black AD, Car J, Pagliari C, et al. The impact of eHealth on the quality and safety of health care: a systematic overview. PLoS Med 2011;8:e1000387.
31. Sheikh A, Cornford T, Barber N, et al. Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in 'early adopter' hospitals. BMJ 2011;343:d6054.
32. Hunter KM. Doctors' Stories: The Narrative Structure of Medical Knowledge. Princeton, NJ: Princeton University Press, 1991.
33. Tange HJ. Consultation of medical narratives in the electronic medical record. Methods Inf Med 1999;38:289-93. (Pubitemid 30030057)
34. Berg M, Goorman E. The contextual nature of medical information. Int J Med Inform 1999;56:51-60.
35. Greenhalgh T, Hurwitz B. Narrative based medicine: why study narrative? BMJ 1999;318:48-50.
36. Body R, Carley S, Wibberley C, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation 2010;81:281-6.
37. Das AK, Olfson M, Gameroff MJ, et al. Screening for bipolar disorder in a primary care practice. JAMA 2005;293:956-63. (Pubitemid 40271127)
38. Porter SC, Forbes P, Manzi S, et al. Patients providing the answers: narrowing the gap in data quality for emergency care. Qual Safe Health Care 2010;19:e34.
39. Davenport RJ, Dennis MS, Warlow CP. Improving the recording of the clinical assessment of stroke patients using a clerking pro forma. Age Ageing 1995;24:43-8.
40. Day PF, Duggal MS. A multicentre investigation into the role of structured histories for patients with tooth avulsion at their initial visit to a dental hospital. Dent Traumatol 2003;19:243-7. (Pubitemid 37206100)
41. Körner H, Söndenaa K, Söreide JA, et al. Structured data collection improves the diagnosis of acute appendicitis. Br J Surg 1998;85:341-4. (Pubitemid 28098619)
42. Michele H, Amegavie L. Developing a paediatric asthma review pro forma. Nurs Stand 2005;19:33-40.
43. Fung CH. Computerized condition-specific templates for improving care of geriatric syndromes in a primary care setting. J Gen Intern Med 2006;21:989-94. (Pubitemid 44141771)
44. Wallace SA, Gullan RW, Byrne PO, et al. Use of a pro forma for head injuries in the accident and emergency departmentdthe way forward. J Accid Emerg Med 1994;11:33-42. (Pubitemid 24232399)
45. Hedges J, Mann CN, Meischke H, et al. Assessment of chest pain onset and out-of-hospital delay using standardized interview questions: the REACT Pilot Study. Rapid Early Action for Coronary Treatment (REACT) Study Group. Acad Emerg Med 1998;5:773-80. (Pubitemid 28367209)
46. Lilford RJ, Kelly M, Baines A, et al. Effect of using protocols on medical care: randomised trial of three methods of taking an antenatal history. BMJ 1992;305:1181-4.
47. Berg M, Langenberg C, vd Berg I, et al. Considerations for sociotechnical design: experiences with an electronic patient record in a clinical context. Int J Med Inform 1998;52:243-51. (Pubitemid 28529660)
48. Haughton J. A paradigm shift in healthcare. From disease management to patient-centered systems. MD Comput 2000;17:34-8.
49. Murff HJ, FitzHenry F, Matheny ME, et al. Automated identification of postoperative complications within an electronic medical record using natural language processing. JAMA 2011;306:848-55.
50. Kawamoto K, Houlihan CA, Balas EA, et al. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ 2005;330:765-72.
51. Personalized Health Care: Pioneers, Partnerships, Progress. US Department of Health and Human Services, 2008. http://www.hhs.gov/myhealthcare/news/phc- 2008-report.pdf (accessed 1 Dec 2011).
52. Coulter A, Rozansky D. Full engagement in health. BMJ 2004;329:1197-8. (Pubitemid 39551439)
53. Prokosch HU, Ganslandt T. Perspectives for medical informatics. Reusing the electronic medical record for clinical research. Methods Inf Med 2009;48:38-44.