Impacts of structuring the electronic health record: Results of a systematic literature review from the perspective of secondary use of patient data

doi:10.1016/j.ijmedinf.2016.10.004

International Journal of Medical Informatics

Volume 97, January 2017, Pages 293-303

https://doi.org/10.1016/j.ijmedinf.2016.10.004 Get rights and content

Highlights

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The impact of various methods for structuring EHR content – incl. both at the time of care and post hoc structuring approaches – were reviewed from the viewpoint of secondary use of data.
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Information and system quality were common evaluation topics, and the evaluation outcomes were structure and context sensitive.
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Evaluation of NLP-applications and their potential in free text re-use in the secondary use context is the predominant research focus of an increasing number of studies after 2005. Parallel to NLP-application evaluations, research of ad hoc structuring methods showed a clear increase in volume after 2000.
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The benefits of standardized structured EHR data warrant further research, as potential benefits in the secondary use context are based on standardized and interoperable structured patient data.
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Common evaluation methods would enhance comparable studies on structuring methods to generate more standardized results to be used in evidence-based policy making.

Abstract

Purpose

To explore the impacts that structuring of electronic health records (EHRs) has had from the perspective of secondary use of patient data as reflected in currently published literature. This paper presents the results of a systematic literature review aimed at answering the following questions; (1) what are the common methods of structuring patient data to serve secondary use purposes; (2) what are the common methods of evaluating patient data structuring in the secondary use context, and (3) what impacts or outcomes of EHR structuring have been reported from the secondary use perspective.

Methods

The reported study forms part of a wider systematic literature review on the impacts of EHR structuring methods and evaluations of their impact. The review was based on a 12-step systematic review protocol adapted from the Cochrane methodology. Original articles included in the study were divided into three groups for analysis and reporting based on their use focus: nursing documentation, medical use and secondary use (presented in this paper). The analysis from the perspective of secondary use of data includes 85 original articles from 1975 to 2010 retrieved from 15 bibliographic databases.

Results

The implementation of structured EHRs can be roughly divided into applications for documenting patient data at the point of care and application for retrieval of patient data (post hoc structuring). Two thirds of the secondary use articles concern EHR structuring methods which were still under development or in the testing phase.

Methods

of structuring patient data such as codes, terminologies, reference information models, forms or templates and documentation standards were usually applied in combination. Most of the identified benefits of utilizing structured EHR data for secondary use purposes concentrated on information content and quality or on technical quality and reliability, particularly in the case of Natural Language Processing (NLP) studies. A few individual articles evaluated impacts on care processes, productivity and costs, patient safety, care quality or other health impacts. In most articles these endpoints were usually discussed as goals of secondary use and less as evidence-supported impacts, resulting from the use of structured EHR data for secondary purposes.

Conclusions

Further studies and more sound evaluation methods are needed for evidence on how EHRs are utilized for secondary purposes, and how structured documentation methods can serve different users’ needs, e.g. administration, statistics and research and development, in parallel to medical use purposes.

Introduction

Electronic Health Record (EHR) systems have been widely implemented in health care organizations and are in routine use in most European countries [1]. The European aim is to promote high-quality health care delivery with efficient and integrated services [2]. To support achievement of this aim, several countries have progressed from local to national information systems, including Finland where the decision has been made to extensively document patient data in a structured form at the point of care. National level systems offer health care professionals and other authorized user groups access to patients’ data regardless of where it has been produced and for a variety of purposes beyond patient care, collectively referred to as ‘secondary use of data’.

Secondary use of patient data has been defined as “non-direct care use of Personal Health Information including but not limited to analysis, research, quality/safety measurement, public health, payment, provider certification or accreditation, and marketing and other business including strictly commercial activities” [3].

Completeness and interoperability of health data are key requirements when patient information is to be utilized for secondary purposes and also constitute main goals in developing structured patient records. In most large-scale development cases, standardized patient information is indeed seen as crucial. Structured patient information is perceived to support clinical processes and evidence-based practices. It is expected to facilitate new technologies for patient safety and care quality monitoring in health care service processes [5]. On the other hand, free text documentation is typically deemed as important by primary users of EHR data, who are highly concerned that important information could otherwise be omitted.

In spite the wide and extensive implementations of EHRs, evidence regarding the impacts – positive and negative – of structuring EHR data remains limited. We set out to fill this gap by means of a systematic literature review exploring the impacts that structuring of electronic health records (EHRs) has had from the perspective of secondary use of data. The study is part of a larger systematic literature review on the impacts of EHR data structures and various structuring methods from three different perspectives: nursing [6], medical use [7] and secondary use. This paper reports on (1) what methods of structuring patient data are applied for secondary use purposes, (2) what the common methods of evaluating patient data structuring are in the secondary use context, and (3) what outcomes have been reported from the secondary use perspective.

Section snippets

Methods and description of study material

The systematic literature review on the impacts of structuring the EHR was designed as a 12-step research protocol based on Cochrane reviews and protocols [8]. Our methods – the review protocol, search strategy, databases searched, exclusion and inclusion criteria and the analytical framework – have been detailed in an earlier publication [5]. Literature searches were conducted in 15 bibliographic databases, for which search strategies were defined along PICO-elements: population, intervention,

Structuring patient data for secondary use purposes

Methods for structuring patient records are described in Table 2. Of the reviewed articles, 30% studied combinations of patient data structuring methods, and 26% evaluated specific code sets, classifications or terminologies. Documentation standards or standardized forms for data entry were evaluated in 19% of the articles. In 16% of the articles, the structures consisted of narrative, free text entries, whereby structuring took place after primary documentation of care. Structuring patient

Discussion

Data documented in structured patient records is required to be sufficiently complete, uniformly coded and documented in order to be reliable and interoperable for utilization in contexts other than direct patient care, such as for secondary use purposes. Various methods of structuring, such as classifications, terminologies and documentation standards can support achievement of this goal and, in most cases, can be used in combination within an EHR. Two main secondary use themes emerged in our

Conclusions

The most prominent secondary users’ viewpoint in the reviewed articles was that of researchers and developers building improved EHRs and integrated NLP- and DSS-tools. Although structured documentation contributed to more complete and reliable records, there was limited evidence that structured EHRs would result in higher quality care of patients. Further studies will need to provide valuable evidence on how structured patient data in EHRs is utilized for secondary purposes, and how

Conflict of interest

No reported conflict of interests although Päivi Mäkelä-Bengs and Riikka Vuokko are involved in the definition of obligatory EHR structured data for the Finnish national eHealth architecture.

Author contributions

All the authors contributed to the wider review methodology development and its implementation, the analysis of articles reported in this paper, as well as drafting the original text. Riikka Vuokko and Persephone Doupi had the main responsibility for subsequent revisions and producing the final version of the article. Päivi Mäkelä-Bengs and Persephone Doupi provided medical expertise and Hannele Hyppönen had the main responsibility of the systematic literature review project.

Acknowledgement

The authors wish to thank Matt Cobb for suggestions on how to improve clarity of the article.

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Review articleImpacts of structuring the electronic health record: Results of a systematic literature review from the perspective of secondary use of patient data

Highlights

Abstract

Purpose

Methods

Results

Methods

Conclusions

Introduction

Section snippets

Methods and description of study material

Structuring patient data for secondary use purposes

Discussion

Conclusions

Conflict of interest

Author contributions

Acknowledgement

Int. J. Med. Inf.

Pathology

Surgery

Am. J. Geriatr. Pharmacother.

J. Crit. Care

J. Am. Med. Inform. Assoc.

J. Am. Med. Inform. Assoc.

J. Am. Coll. Surg.

J. Am. Coll. Surg.

Joint Comm. J. Qual. Improv.

Am. J. Prev. Med.

Joint Comm. J. Qual. Saf.

Comput. Biol. Med.

Int. J. Med. Inf.

J. Hosp. Infect.

J. Am. Med. Inform. Assoc.

Int. J. Med. Inf.

J. Biomed. Inform.

Am. Heart J.

J. Am. Med. Inform. Assoc.

Am. J. Emerg. Med.

Health Policy

J. Clin. Epidemiol.

J. Am. Med. Inform. Assoc.

J. Am. Med. Inform. Assoc.

J. Am. Med. Inform. Assoc.

J. Am. Med. Inform. Assoc.

Int. J. Med. Inf.

Benchmarking health IT among OECD countries: better data for better policy

J. Am. Med. Inform. Assoc.

Toward a national framework for the secondary use of health data, an american medical informatics association white paper

Am. Med. Inform. Assoc.

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

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Impacts of structuring nursing records: a systematic review

Scand. J. Caring Sci.

The DeLone and McLean model of information systems success: a ten-year update

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Secondary use of structured patient data: interim results of a systematic review

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An evaluation of hospital discharge records as a tool for serious work related injury surveillance

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Evaluation of the Turkish translation of the Minimal Standard Terminology for Digestive Endoscopy by development of an endoscopic information system

Turk. J. Gastroenterol.

Improving the quality of the coding of primary diagnosis in standardized discharge summaries

Health Care Manage. Sci.

Automated review of electronic health records to assess quality of care for outpatients with heart failure

Ann. Intern. Med.

Assessing data adequacy for clinical research: reliability and validity of a surgical database

J. Nurs. Meas.

Evaluation of the quality of information retrieval of clinical findings from a computerized patient database using a semantic terminological model

J. Am. Med. Inform. Assoc.

Medical Practitioners Act 2007: the increased medical record burden

Ir. Med. J.

Assessment of the validity and reliability of three systems of medical record screening for quality of care assessment

Med. Care

Reporting hospital adverse events using the Alfred Hospital's morbidity data

Aust. Health Rev.

Innovations: medical record standards compliance as a function of selected staff variables

Top. Health Rec. Manage.

Setting the records straight-a prospective audit of the quality of case notes in a surgical department

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Fever detection from free-text clinical records for biosurveillance

Review article
Impacts of structuring the electronic health record: Results of a systematic literature review from the perspective of secondary use of patient data