Clinical Summarization Capabilities of Commercially-available and Internally-developed Electronic Health Records

A. Laxmisan; A.B. McCoy; A. Wright; D.F. Sittig

doi:10.1055/s-0037-1618556

Applied Clinical Informatics, Table of Contents

Appl Clin Inform 2012; 03(01): 80-93
DOI: 10.1055/s-0037-1618556

Research Article

Schattauer GmbH

Clinical Summarization Capabilities of Commercially-available and Internally-developed Electronic Health Records

A. Laxmisan

¹Houston VA Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX

,

A.B. McCoy

²School of Biomedical Informatics, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX

,

A. Wright

³Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

,

D.F. Sittig

²School of Biomedical Informatics, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX

› Author Affiliations

Abstract

Summary

Objective: Clinical summarization, the process by which relevant patient information is electronically summarized and presented at the point of care, is of increasing importance given the increasing volume of clinical data in electronic health record systems (EHRs). There is a paucity of research on electronic clinical summarization, including the capabilities of currently available EHR systems.

Methods: We compared different aspects of general clinical summary screens used in twelve different EHR systems using a previously described conceptual model: AORTIS (Aggregation, Organization, Reduction, Interpretation and Synthesis).

Results: We found a wide variation in the EHRs’ summarization capabilities: all systems were capable of simple aggregation and organization of limited clinical content, but only one demonstrated an ability to synthesize information from the data.

Conclusion: Improvement of the clinical summary screen functionality for currently available EHRs is necessary. Further research should identify strategies and methods for creating easy to use, well-designed clinical summary screens that aggregate, organize and reduce all pertinent patient information as well as provide clinical interpretations and synthesis as required.

Keywords

Electronic health records - clinical summarization - user interface

Full Text

References

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