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Pre-defined Headings in a Multiprofessional Electronic Health Record System
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Research in Disability and Habilitation. (Forskning om funktionshinder och habilitering)
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Research in Disability and Habilitation. (Forskning om funktionshinder och habilitering)
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Research in Disability and Habilitation. (Forskning om funktionshinder och habilitering)
2012 (English)In: Scandinavian Conference onHealth Informatics 2012October 2–3 oktober, Linköping, Sverige / [ed] Karlsson, Daniel ; Bellika, Johan Gustav ; Elberg, Pia Britt ; Fossum, Mariann ; Galster, Gert ; Hartvigsen, Gunnar ; Koch, Sabine ; Nilsson, Gunilla, Linköping, 2012, Vol. 19, no 6, 61-61 p.Conference paper, Poster (with or without abstract) (Refereed)
Abstract [en]

Background Applying multiprofessional electronic health records (EHRs) is expected to improve the quality of patient care and patient safety. Both EHR systems and system users depend on semantic interoperability to function efficiently. A shared clinical terminology comprising unambiguous terms is required for semantic interoperability. Empirical studies of clinical terminology, such as predefined headings, in EHR systems are scarce and limited to one profession or one clinical specialty.

Objective To study predefined headings applied by users in a Swedish multiprofessional EHR system.

Materials and methods This was a descriptive study of predefined headings (n=3596) applied by 5509 users in a Swedish multiprofessional EHR system. The predefined headings were classified into four term and word categories.

Results Less than half of the predefined headings were shared by two or more professional groups. All eight professionals groups shared 1.7% of the predefined headings. The distribution of predefined headings across categories yielded two-thirds “terms for special purposes” and “specialist terms” and one-third “common words” and “unclassified headings”.

Discussion The indicated presence of profession-specific predefined headings and the conflict between ambiguity and comprehension of terms and words used as headings are discussed.

Conclusions The predefined headings in the multiprofessional EHR system studied did not constitute a joint language for specific purposes. The improvement of the quality and usability of multiprofessional EHR systems requires attention.

Place, publisher, year, edition, pages
Linköping, 2012. Vol. 19, no 6, 61-61 p.
National Category
Other Health Sciences
Research subject
Medical Science
Identifiers
URN: urn:nbn:se:uu:diva-182495OAI: oai:DiVA.org:uu-182495DiVA: diva2:559993
Conference
Scandinavian Conference on Health Informatics 2012October 2–3 oktober, Linköping, Sverige
Available from: 2012-10-11 Created: 2012-10-11 Last updated: 2014-04-04

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http://www.ep.liu.se/ecp/070/ecp12070.pdf

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Terner, AnnikaLindstedt, HelenaSonnander, Karin

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