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Literature Review of Patient Record Structures from the Physician’s Perspective

  • Systems-Level Quality Improvement
  • Published:
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Abstract

The Finnish Patient Data Repository is a nationwide electronic health record (EHR) system collecting patient data from all healthcare providers. The usefulness of the large amount of data stored in the system depends on the underlying data structures, and thus a solid understanding of these structures is in focus in further development of the data repository. This study seeks to improve that understanding by a systematic literature review. The review takes the physician's perspective to the use and usefulness of the data structures. The articles included in this review study data structures intended to be used in the actual care process. Secondary use and nursing aspects have been covered in separate reviews. After applying the predefined inclusion and exclusion criteria only 40 articles were included in the review. The research on widespread systems in everyday use was especially scarce, most studies concentrated on narrow fields. Majority of these studies were primarily developed for specialist use in secondary care units. Most structures or applications studied were at an early stage of development. In many applications the use of structured data was found to improve the completeness of the documented data and facilitate its automated use. However, there seem to be some applications where narrative text cannot be easily replaced by structured data. Usability results regarding structured representation were conflicting. The scattered nature and paucity of research hinders the generalizability of the findings, and from the system design or implementation point of view the practical value of the scientific literature reviewed is limited.

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Notes

  1. Finnish population is approximately 5.5 million people.

References

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Author information

Authors and Affiliations

  1. Department of Signal Processing, Tampere University of Technology, P.O. Box 553, FI-33101, Tampere, Finland

    Heikki Forsvik & Ville Voipio

  2. General Practice/Family Medicine, University of Turku, Turku, Finland

    Heikki Forsvik

  3. Department of Industrial Management, Tampere University of Technology, Tampere, Finland

    Johanna Lamminen

  4. Information Services Department, National Institute for Health and Welfare, Helsinki, Finland

    Persephone Doupi, Hannele Hyppönen & Riikka Vuokko

Authors
  1. Heikki Forsvik
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  2. Ville Voipio
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  3. Johanna Lamminen
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  4. Persephone Doupi
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  5. Hannele Hyppönen
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  6. Riikka Vuokko
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Corresponding author

Correspondence to Heikki Forsvik.

Additional information

This article is part of the Topical Collection on Systems-Level Quality Improvement

Appendix A – List of articles reviewed

Appendix A – List of articles reviewed

  1. 1.

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    Aronsky, D., Haug, PJ. Assessing the quality of clinical data in a computer-based record for calculating the Pneumonia Severity Index. Journal of the American Medical Informatics Association. 2000 JAN-FEB;7(1):55-65.

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    Aronsky, D., Kasworm, E., Jacobson, J. A., Haug, P. J. and Dean, N. C. Electronic screening of dictated reports to identify patients with do-not-resuscitate status. Journal of the American Medical Informatics Association. 2004 Sep-Oct;11(5):403-9.

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    Bar-on, M. E., Zanga, J. R. Child abuse: a model for the use of structured clinical forms. Pediatrics. 1996 Sep;98(3 Pt 1):429-33.

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    Carl-F., Bassøe. Automated diagnoses from clinical narratives: A medical system based on computerized medical records, natural language processing, and neural network technology. Neural Networks. 1995;8(2):313-9.

  6. 6.

    Bell, D. S., Greenes, R. A. Evaluation of UltraSTAR: performance of a collaborative structured data entry system. Proceedings - the Annual Symposium on Computer Applications in Medical Care. 1994:216-22.

  7. 7.

    Biffl, W. L., Harrington, D. T. and Cioffi, W. G. Implementation of a tertiary trauma survey decreases missed injuries. Journal of Trauma-Injury Infection & Critical Care. 2003 discussion 43-4; Jan;54(1):38-43.

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    Brown, M. L., Quinonez, L. G. and Schaff, H. V. A pilot study of electronic cardiovascular operative notes: qualitative assessment and challenges in implementation. J Am Coll Surg. 2010 Feb. 210(2):178-84.

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    Brown, S. H., Lincoln, M., Hardenbrook, S., et al. Derivation and evaluation of a document-naming nomenclature. Journal of the American Medical Informatics Association. 2001 Jul-Aug. 8(4):379-90.

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    Geist, S. M., Geist, J. R. Improvement in medical consultation responses with a structured request form. J Dent Educ. 2008 May;72(5):553-61.

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  16. 16.

    Los, R. K., van Ginneken, A. M., Roukema, J., Moll, H. A. and van der Lei, J. Why are structured data different? Relating differences in data representation to the rationale of OpenSDE. Medical Informatics & the Internet in Medicine. 2005 Dec;30(4):267-76.

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    Marill, K. A., Gauharou, E. S., Nelson, B. K., Peterson, M. A., Curtis, R. L. and Gonzalez, M. R. Prospective, randomized trial of template-assisted versus undirected written recording of physician records in the emergency department. Ann Emerg Med. 1999 May; 33(5):500-9.

  19. 19.

    Mayo, N. E., Poissant, L., Ahmed, S., et al. Incorporating the International Classification of Functioning, Disability, and Health (ICF) into an electronic health record to create indicators of function: proof of concept using the SF-12. Journal of the American Medical Informatics Association. 2004 Nov-Dec;11(6):514-22.

  20. 20.

    Meystre, S. M., Haug, P. J. Randomized controlled trial of an automated problem list with improved sensitivity. Int J Med Inf. 2008 Sep; 77(9):602-12.

  21. 21.

    Meystre, S. M., Haug, P. J. Comparing natural language processing tools to extract medical problems from narrative text. AMIA …Annual Symposium Proceedings/AMIA Symposium: 525-9, 2005.

  22. 22.

    Meystre, S., Haug, P. Improving the sensitivity of the problem list in an intensive care unit by using natural language processing. AMIA…Annual Symposium proceedings / AMIA Symposium.AMIA Symposium.554-8p.2006.

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    Meystre, S. Haug, PJ. Natural language processing to extract medical problems from electronic clinical documents: Performance evaluation. J Biomed Inform. 2006 12; 39(6):589-99.

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  26. 26.

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  27. 27.

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  28. 28.

    Roukema, J., Los, R. K., Bleeker, S. E., van Ginneken, AM, J and Moll, H. A. Paper versus computer: feasibility of an electronic medical record in general pediatrics. Pediatrics. 2006;117(1):15-21.

  29. 29.

    Schleyer, T., Spallek, H. and Hernandez, P. A qualitative investigation of the content of dental paper-based and computer-based patient record formats. J Am Med Inform Assoc. 2007 2007;14(4):515-26.

  30. 30.

    Shapiro, J. S., Bakken, S., Hyun, S., Melton, G. B., Schlegel, C. and Johnson, S. B. Document ontology: supporting narrative documents in electronic health records. AMIA …Annual Symposium Proceedings/AMIA Symposium.:684-8, 2005.

  31. 31.

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  35. 35.

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    Treece, P. D., Engelberg, R. A., Crowley, L., et al. Evaluation of a standardized order form for the withdrawal of life support in the intensive care unit. Crit Care Med. 2004 May;32(5):1141-8.

  37. 37.

    Van Vleck, T. T., Stein, D. M., Stetson, P. D. and Johnson, S. B. Assessing data relevance for automated generation of a clinical summary. AMIA …Annual Symposium Proceedings/AMIA Symposium.:761-5, 2007.

  38. 38.

    Van Walraven, C., Duke, S. M., Weinberg, A. L. and Wells, P. S. Standardized or narrative discharge summaries. Which do family physicians prefer? Canadian Family Physician. 1998 Jan;44:62-9.

  39. 39.

    Wasserman, H., Wang, J. An applied evaluation of SNOMED CT as a clinical vocabulary for the computerized diagnosis and problem list. AMIA ..Annual Symposium Proceedings/AMIA Symposium.:699-703, 2003.

  40. 40.

    White, J. M., Kalenderian, E., Stark, P. C., Ramoni, R. L., Vaderhobli, R. and Walji, M. F. Evaluating a dental diagnostic terminology in an electronic health record. J Dent Educ. 2011 May;75(5):605-15.

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Forsvik, H., Voipio, V., Lamminen, J. et al. Literature Review of Patient Record Structures from the Physician’s Perspective. J Med Syst 41, 29 (2017). https://doi.org/10.1007/s10916-016-0677-0

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  • DOI: https://doi.org/10.1007/s10916-016-0677-0

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