Subscribe to RSS
Use of Headings and Classifications by Physicians in Medical Narratives of EHRsAn evaluation study in a Finnish hospital
16 December 2010
Accepted: 22 March 2011
16 December 2017 (online)
Objective: The purpose of this study was to describe and evaluate patient care documentation by hospital physicians in EHRs and especially the use of national headings and classifications in these documentations Material and Methods: The initial material consisted of a random sample of 3,481 medical narratives documented in EHRs during the period 2004-2005 in one department of a Finnish central hospital. The final material comprised a subset of 1,974 medical records with a focus on consultation requests and consultation responses by two specialist groups from 871 patients. This electronic documentation was analyzed using deductive content analyses and descriptive statistics.
Results: The physicians documented patient care in EHRs principally as narrative text. The medical narratives recorded by specialists were structured with headings in less than half of the patient cases. Consultation responses in general were more often structured with headings than consultation requests. The use of classifications was otherwise insignificant, but diagnoses were documented as ICD 10 codes in over 50% of consultation responses by both medical specialties.
Conclusion: There is an obvious need to improve the structuring of narrative text with national headings and classifications. According to the findings of this study, reason for care, patient history, health status, follow-up care plan and diagnosis are meaningful headings in physicians’ documentation. The existing list of headings needs to be analyzed within a consistent unified terminology system as a basis for further development. Adhering to headings and classifications in EHR documentation enables patient data to be shared and aggregated. The secondary use of data is expected to improve care management and quality of care.
- 1 Tange HJ, Hasman A, de Vries Robbe PF, Schouten HC. Medical narratives in electronic medical records. Int J Med Inf 1997; 46 (Suppl. 01) 7-29.
- 2 Grimson J. Delivering the electronic healthcare record for the 21st century. Int J Med Inf 2001; 64 2-3 111-127.
- 3 van Ginneken AM. The computerized patient record: balancing effort and benefit. Int J Med Inf 2002; 65 (Suppl. 02) 97-119.
- 4 Shortliffe EH, Perreault LE. editors. Medical Informatics: Computer Applications in Health Care and Biomedicine. Second ed. New York: Springer-Verlag; 2001
- 5 Haux R. Health information systems –past, present, future. Int J Med Inf 2006; 75 3-4 268-281.
- 6 ISO/TR 20514.. Health Informatics –Electronic health record –definition, scope, and context 2005.
- 7 European Commission.. eHealth –making health care better for European citizens: An Action Plan for the European eHealth Area 2004.
- 8 European Commission.. Connected Health: Quality and Safety for European Citizens 2006.
- 9 Haux R, Ammenwerth E, Herzog W, Knaup P. Health care in the information society. A prognosis for the year 2013. Int J Med Inf 2002; 66: 3.
- 10 McDonald CJ. The barriers to electronic medical record systems and how to overcome them. J Am Med Inform Assoc 1997; 4 (Suppl. 03) 213-221.
- 11 Boonstra A, Broekhuis M. Barriers to the acceptance of electronic medical records by physicians from systematic review to taxonomy and interventions. BMC Health Serv Res 2010; 10: 231.
- 12 Rosenbloom ST, Stead WW, Denny JC. et al. Generating clinical notes for electronic health record systems. Appl Clin Inform 2010; 1 (Suppl. 03) 232-243.
- 13 Mäkelä K, Virjo I, Aho J. et al. Management of electronic patient record systems in primary healthcare in a finnish county. Telemed J E Health 2010; 16 (Suppl. 10) 1017-1023.
- 14 Chaudhry B, Wang J, Wu S. et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med 2006; 144 (Suppl. 10) 742-752.
- 15 Tang PC, LaRosa MP, Gorden SM. Use of computer-based records, completeness of documentation, and appropriateness of documented clinical decisions. J Am Med. Inform Assoc 1999; 6 (Suppl. 03) 245-251.
- 16 Delpierre C, Cuzin L, Fillaux J. et al. A systematic review of computer-based patient record systems and quality of care: more randomized clinical trials or a broader approach?. Int J Qual Health Care 2004; 16 (Suppl. 05) 407-416.
- 17 Vainiomaki S, Kuusela M, Vainiomaki P, Rautava P. The quality of electronic patient records in Finnish primary healthcare needs to be improved. Scand J Prim Health Care 2008; 26 (Suppl. 02) 117-122.
- 18 Weir CR, Hurdle JF, Felgar MA. et al. Direct text entry in electronic progress notes. An evaluation of input errors. Methods Inf Med 2003; 42 (Suppl. 01) 61-67.
- 19 Häyrinen K, Saranto K, Nykänen P. Definition, structure, content, use and impacts of electronic health records: a review of the research literature. Int J. Med. Inform 2008; 77 (Suppl. 05) 291-304.
- 20 Meystre SM, Savova GK, Kipper-Schuler KC, Hurdle JF. Extracting information from textual documents in the electronic health record: a review of recent research. Yearb Med Inform 2008: 128-144.
- 21 Bossen C. Evaluation of a computerized problem-oriented medical record in a hospital department: does it support daily clinical practice?. Int J Med Inform 2007; 76 (Suppl. 08) 592-600.
- 22 Ho LM, McGhee SM, Hedley AJ, Leong JC. The application of a computerized problem-oriented medical record system and its impact on patient care. Int J. Med Inform 1999; 55 (Suppl. 01) 47-59.
- 23 Tange HJ, Schouten HC, Kester AD, Hasman A. The granularity of medical narratives and its effect on the speed and completeness of information retrieval. J Am Med Inform Assoc 1998; 5 (Suppl. 06) 571-582.
- 24 Ammenwerth E, de Keizer N. An inventory of evaluation studies of information technology in health care trends in evaluation research 1982-2002. Methods Inf Med 2005; 44 (Suppl. 01) 44-56.
- 25 Thiru K, Hassey A, Sullivan F. Systematic review of scope and quality of electronic patient record data in primary care. BMJ 2003; 326 7398 1070-1072.
- 26 Chan KS, Fowles JB, Weiner JP. Review: electronic health records and the reliability and validity of quality measures: a review of the literature. Med. CareRes Rev 2010; 5: 503-527.
- 27 Kay S. Ontological and epistemological views of ‘headings’ in clinical records. Stud Health Technol Inform 2001; 84 Pt 1 104-108.
- 28 Åhlfeldt H, Ehnfors M, Ridderstolpe L. Towards a multi-professional patient record--a study of the headings used in clinical practice. Proc AMIA Symp 1999: 7-11.
- 29 Rossi Mori A, Consorti F. Structures of clinical information in patient records. Proc AMIA Symp 1999: 132-136.
- 30 Ministry of Social Affairs and Health.. Decree of the Ministry of Social Affairs and Health on Patient Documentation. 30.3.2009/298.
- 31 Iivari A, Ruotsalainen P. eHealth Roadmap –Finland., 2007. Ministry of Social Affairs and Health Reports 2007:15. Ministry of Social Affairs and Health, Helsinki.
- 32 Hyun S, Bakken S. Toward the creation of an ontology for nursing document sections: mapping section names to the LOINC semantic model. AMIA Annu Symp Proc 2006: 364-368.
- 33 The standardized data content of national EHR.. Guide to implementation of the core data elements, headings, and documents as well as structured data elements of specialties and activities in EHR. Version
- 34 National Institute of Health and Welfare.. Code server 2011. Finnish. Available from: http://sty.stakes.fi/FI/koodistopalvelu/koodisto.htm.
- 35 Health Level 7 Finland 2011.. Finnish. Available from: www.hl7.fi.
- 36 Yusuff KB, Tayo F. Does a physician’s specialty influence the recording of medication history in patients’ case notes?. Br J Clin Pharmacol 2008; 66 (Suppl. 02) 308-312.