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

Journal of the American Medical Informatics Association

Volumn 21, Issue 3, 2014, Pages 492-500

  Morrison, Zoe ^a   Fernando, Bernard ^a   Kalra, Dipak ^b   Cresswell, Kathrin ^a   Sheikh, Aziz ^a,c  

^a UNIVERSITY OF EDINBURGH   (United Kingdom)

^b UNIVERSITY COLLEGE LONDON   (United Kingdom)

^c BRIGHAM AND WOMEN S HOSPITAL   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ADMINISTRATIVE PERSONNEL; ARTICLE; CLINICAL PRACTICE; ELECTRONIC MEDICAL RECORD; EXPLORATORY RESEARCH; FEMALE; HEALTH CARE PERSONNEL; HEALTH SERVICE; HUMAN; MALE; MANAGER; MEDICAL DOCUMENTATION; PATIENT CARE; PATIENT CODING; PRACTICE GUIDELINE; QUALITATIVE RESEARCH; RISK BENEFIT ANALYSIS; SECONDARY ANALYSIS; SECONDARY HEALTH CARE; UNITED KINGDOM; ATTITUDE TO HEALTH; CODING; DATA STRUCTURE; ELECTRONIC PATIENT RECORDS; HEALTH PERSONNEL ATTITUDE; HOSPITAL PERSONNEL; INTERVIEW; NATIONAL HEALTH SERVICE; ORGANIZATION AND MANAGEMENT; PATIENT COMMUNICATION; REIMBURSEMENT;

CLINICAL CODING; DATA STRUCTURE; ELECTRONIC HEALTH RECORDS; ELECTRONIC PATIENT RECORDS; PATIENT COMMUNICATION;

ATTITUDE OF HEALTH PERSONNEL; ATTITUDE TO HEALTH; CLINICAL CODING; ELECTRONIC HEALTH RECORDS; FEMALE; GREAT BRITAIN; HUMANS; INTERVIEWS AS TOPIC; MALE; PATIENT CARE; PERSONNEL, HOSPITAL; QUALITATIVE RESEARCH; REIMBURSEMENT MECHANISMS; STATE MEDICINE;

EID: 84901848699     PISSN: 10675027     EISSN: 1527974X     Source Type: Journal    
DOI: 10.1136/amiajnl-2013-001666     Document Type: Article

References (62)

1. Blumenthal D. Launching HITECH. N Engl J Med 2010;362:382-5.
2. 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.
3. Department of Health. The power of information: putting all of us in control of the health and care information we need. 21 May 2012. http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_134181 (accessed 24 May 2012).
4. Department for Business Innovation and Skills. Strategy for UK Life Sciences, December 2011. https://www.gov.uk/government/uploads/system/uploads/ attachment_data/file/32457/11-1429-strategy-for-uk-life-sciences.pdf (accessed 8 Feb 2012).
5. 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 Healthc Eng 2011;2:25-42.
6. Fernando B, Kalra D, Morrison Z, et al. Benefits and risks of structuring and coding the presenting patient history in the electronic health record: systematic review. BMJ Qual Saf 2012;21:337-46.
7. Lilford RJ, Thornton JD. Decision logic in medical practice. The Milroy Lecture 1992. J R Coll Physicians 1992;26:400-12.
8. De Lusignan S. Codes, classifications, terminologies and nomenclatures: definition, development and application in practice. Inform Prim Care 2005;13:65-9.
9. Butler CC, Evans M, et al. The 'heartsink' patient revisited. Br J Gen Pract 1999;49:230-3.
10. Goldstein-Jutel A. Putting a name to it: diagnosis in contemporary society. Baltimore: John Hopkins University Press, 2011.
11. De Lusignan S. The barriers to clinical coding in general practice: a literature review. Med Inform Internet Med 2005;30:89-97.
12. O'Dowd A. Coding errors in NHS cause up to €1bn worth of inaccurate payments. BMJ 2010;341:c4734.
13. The Scottish Government. The healthcare quality strategy for NHS Scotland. 2010. http://www.scotland.gov.uk/Resource/Doc/311667/0098354.pdf (accessed 27 Oct 2013).
14. The Scottish Government. Patient Rights (Scotland) Act. 2011. http://www. legislation.gov.uk/asp/2011/5/contents (accessed 27 Oct 2013).
15. Greist JH, Laughren TP, Gustafson DH. A computer interview for suicide-risk prediction. Am J Psychiatry 1973;130:1327-32.
16. Porter SC, Silvia MT, Fleisher GR, et al. Parents as direct contributors to the medical record: validation of their electronic input. Ann Emerg Med 2000;35:346-52.
17. Porter SC, Kohane IS. Optimal data entry by patients: effects of interface structure and design. Stud Health Technol Inform 2001;84(Pt 1):141-5.
18. Hershey CO, Grant BJB. Controlled trial of a patient-completed history questionnaire: effects on quality of documentation and patient and physician satisfaction. Am J Med Qual 2002;17:126-35.
19. O'Connell R, Poljak A, Powsner S, et al. Forms that inform. Methods Inf Med 2004;43:247-55.
20. Porter SC, Forbes P, Manzi S, et al. Patients providing the answers: narrowing the gap in data quality for emergency care. Qual Saf Health Care 2010;19:e34.
21. Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977;196:129-36.
22. Donnelly WJ. Righting the medical record. JAMA 1988;260:823-5.
23. Smith RC, Hoppe RB. The patient's story: integrating the patient- and physician-centered approaches to interviewing. Ann Intern Med 1991;115:470-7.
24. Fisher B, Bhavnani V, Winfield M, et al. How patients use access to their full health records: a qualitative study of patients in general practice. J R Soc Med 2009;102:539-44.
25. Donnelly WJ. Taking suffering seriously: a new role for the medical case history. Acad Med 1996;71:730-7.
26. Berg M. Medical work and the computer-based patient record: a sociological perspective. Methods Inf Med 1998;37:294-301.
27. Crowe S, Cresswell K, Robertson A, et al. The case study approach. BMC Med Res Methodol 2011;11:100.
28. George A, Bennett A. Case studies and theory development in the social sciences. Cambridge, MA: MIT Press, 2005.
29. Stake RE. The art of case study research. London: Sage, 1995.
30. Yin R. Case study research, design and methods. Sage, 2009.
31. Aarts J, Doorewaard H, Berg M. Understanding implementation: the case of a computerized physician order entry system in a large Dutch university medical center. J Am Med Inform Assoc 2004;11:207-16.
32. Chiasson MW, Davidson E. Pushing the contextual envelope: developing and diffusing IS theory for health information systems research. Info Organ 2004;14:155-88.
33. Coiera E. Four rules for the reinvention of health care. BMJ 2004;328:1197-9.
34. Doolin B. Sociotechnical networks and information management in health care. Account Manag Info Technol 1999;9:95-114.
35. Pare G. Implementing clinical information systems: a multiple-case study within a US hospital. Health Serv Manage Res 2002;15:71-92.
36. Prout A. Actor-network theory, technology and medical sociology: an illustrative analysis of the metered dose inhaler. Sociol Health Illn 1996;18:198-219.
37. Yusof MM, Kuljis J, Papazafeiropoulou A, et al. An evaluation framework for health information systems: human, organization and technology-fit factors (HOT-fit). Int J Med Inform 2008;77:386-98.
38. Silverman D. Doing qualitative research, a practical handbook. London: Sage, 2000.
39. Britten N. Qualitative research: qualitative interviews in medical research. BMJ 1995;311:251-3.
40. Barbour R. Introducing qualitative research. London: Sage, 2008.
41. Glaser BG, Strauss AL. The discovery of grounded theory. Chicago: Aldine, 1967.
42. Alvesson M, Sköldberg K. Reflexive methodology: new vistas for qualitative research. London: Sage, 2000.
43. Morse J. The significance of saturation. Qual Health Res 1995;5:147-9.
44. Greenhalgh T. Narrative based medicine in an evidence based world. BMJ 1999;318:323-5.
45. Kay S, Purves IN. Medical records and other stories: a narratological framework. Methods Inf Med 1996;35:72-87.
46. Greenhalgh T, Potts HW, Wong G, et al. Tensions and paradoxes in electronic patient record research: a systematic literature review using the meta-narrative method. Milbank Q 2009;87:729-88.
47. Lilford RJ, Bingham P, Fawdry R, et al. The development of on-line history-taking systems in antenatal care. Methods Inf Med 1983;22:189-97.
48. Mcadam WA, Brock BM, Armitage T, et al. Twelve years' experience of computer-aided diagnosis in a district general hospital. Ann R Coll Surg Engl 1990;72:140-6.
49. Slack WV, Bleich HL. The CCC system in two teaching hospitals: a progress report. Int J Med Inform 1999;54:183-96.
50. Coiera E. Building a national health IT system from the middle out. J Am Med Inform Assoc 2009;16:271-3.
51. Weed LL. Medical records that guide and teach. N Engl J Med 1968;278:652-7.
52. Rector AL. Clinical terminology: why is it so hard? Methods Inf Med 1999;38:239-52.
53. Dick RC, Steen EB, Detmer DE. The computer-based patient record. Washington, DC: National Academies Press, 1997.
54. 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 a prospective national evaluation. BMJ 2011;343:d6054.
55. 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.
56. Almann P, Micael J. Successful delivery of information technology in the NHS. BMJ 2011;343:d6663.
57. Patel VL, Kushniruk AW, Yang S, et al. Impact of a computer-based patient record system on data collection, knowledge organization, and reasoning. J Am Med Inform Assoc 2000;7:569-85.
58. Karsh B, Beasley JW, Hagenauer ME. Are electronic medical records associated with improved perceptions of the quality of medical records, working conditions, or quality of working life? Behav Inform Technol 2004;23:327-35.
59. Weed LL. Medical records, medical education, and patient care: the problem-orientated record as a basic tool. Cleveland, OH: Press of Case Western Reserve University, 1969.
60. Smith RC, Hoppe RB. The patient's story: integrating the patient- and physician-centered approaches to interviewing. Ann Intern Med 1991;115:470-7.
61. Donnelly WJ. Viewpoint: patient-centered medical care requires a patient-centered medical record. Acad Med 2005;80:33-8.
62. Reiser SJ. The clinical record in medicine. Part 2: reforming content and purpose. Ann Intern Med 1991;114:980-5.