A review of the empirical evidence of the value of structuring and coding of clinical information within electronic health records for direct patient care.

Kalra, Dipak; Fernando, Bernard; Morrison, Zoe; Sheikh, Aziz

Abstract

Background: 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. Methods: 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. Results: 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. Conclusions: 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.

Citation

KALRA, D., FERNANDO, B., MORRISON, Z. and SHEIKH, A. 2013. A review of the empirical evidence of the value of structuring and coding of clinical information within electronic health records for direct patient care. Informatics in primary care [online], 20(3), pages 171-180. Available from: https://doi.org/10.14236/jhi.v20i3.22

• Journal Article Type: Article
• Acceptance Date: Apr 30, 2013
• Online Publication Date: May 7, 2013
• Publication Date: Sep 30, 2013
• Deposit Date: Aug 27, 2020
• Publicly Available Date: Aug 27, 2020
• Journal: Informatics in primary care
• Print ISSN: 1476-0320
• Electronic ISSN: 1475-9985
• Publisher: BCS, The Chartered Institute for IT
• Peer Reviewed: Peer Reviewed
• Volume: 20
• Issue: 3
• Pages: 171-180
• DOI: https://doi.org/10.14236/jhi.v20i3.22
• Keywords: Family Practice; Health Informatics; Leadership and Management
• Public URL: https://rgu-repository.worktribe.com/output/963508