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Predefined Headings in a Multi-professional Electronic Health Record: Professionals’ Application, Aspects of Health and Health Care and Correspondence to Legal Requirements
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Research in Disability and Habilitation.
2014 (English)Licentiate thesis, comprehensive summary (Other academic)
Abstract [en]

The overall aim of this thesis was to investigate predefined headings in a Swedish county council multi-professional EHR system in terms of their shared application, what aspects of health and health care they reflected, and their correspondence to legal requirements. An analysis of 3 596 predefined headings, applied to 20 398 104 occasions by eight professional groups, was conducted. Less than 2% of the predefined headings were applied by all eight professional groups, whereas 60% were not shared at all between the professional groups. A classification of the predefined headings revealed that 13% were “Specialist terms”, which were the least ambiguous predefined headings, 46% were “Terms for specific purposes”, which are less ambiguous than the “Common words” (28%), which were the most ambiguous predefined headings according to the sociolinguistic method employed. The remaining predefined headings (13%) were sorted into “Unclassified headings”. A qualitative content analysis of the predefined headings yielded 23 subcategories grouped into five categories: Description of the patient, Health care process, Resources employed, Administrative documentation, and Development and research. A comparison of the 23 subcategories to the Patient Data Act showed, first, that 15 of 23 subcategories corresponded to four legal requirements, second, that there were legal requirements with a focus on patient rights that were not being met, and third, that there were eight subcategories of predefined headings that could not be attributed to the legal provisions of the Patient Data Act. In conclusion, the proportion of shared predefined headings in the EHRs was limited. The predefined headings in the multi-professional EHRs did not constitute a joint language for specific purposes. A meaningful structure comprising categories and subcategories of different aspects of health and health care as reflected in the applied predefined headings was identified. The structure reflected a wide range of health and health care. No subcategory corresponded to the three legal requirements concerning patient rights. Future research should include professionals’ and patients’ understanding of predefined headings, the correspondence of documented notes to predefined headings and how the documentation in the EHR has had an impact on patient safety.

Place, publisher, year, edition, pages
Uppsala: Uppsala universitet, 2014. , 30 p.
Keyword [en]
Electronic health records, Headings, Patient Data Act, Health care professionals
National Category
Other Medical Sciences not elsewhere specified
Research subject
Medical Science
Identifiers
URN: urn:nbn:se:uu:diva-246853OAI: oai:DiVA.org:uu-246853DiVA: diva2:794306
Presentation
2014-10-24, Boströmsalen, Uppsala universitet, BMC, Husargatan 3, Uppsala, 09:00 (Swedish)
Supervisors
Available from: 2015-03-12 Created: 2015-03-11 Last updated: 2015-03-12Bibliographically approved
List of papers
1. A Retrospective Analysis of Health, Health Care, and Legal Requirements as Reflected in Predefined Headings in an EHR
Open this publication in new window or tab >>A Retrospective Analysis of Health, Health Care, and Legal Requirements as Reflected in Predefined Headings in an EHR
2015 (English)In: Electronic Journal of Health Informatics, ISSN 1446-4381, E-ISSN 1446-4381, Vol. 9, no 1, e9Article in journal (Refereed) Published
Abstract [en]

Objectives

To study health, health care, and legal requirements as reflected in predefined headings that were applied by users in a Swedish multi-professional electronic health record (EHR).

Methods

Predefined headings (n = 3 596) applied to 20 398 104 occasions by health care professionals in a module for care documentation in an EHR were analysed. A conventional qualitative content analysis was used to explore health and health care as reflected in the predefined headings. Furthermore, a comparison was made between the health and health care aspects and the Swedish Patient Data Act (PDA) to examine whether the aspects corresponded to legal requirements.

Results

The analysis yielded a meaningful structure that included five categories and 23 subcategories. The categories were Description of the patient, Health care process, Resources employed, Administrative documentation, and Development and research. Of the 23 subcategories, 15 corresponded to four of the seven legal requirements in the PDA. No corresponding subcategories were observed for three of the legal requirements.

Conclusions

The predefined headings of the multi-professional EHR were possible to analyse and categorise. The analysis showed that the headings reflected a wide range of health and health care and that synonyms or similar terms occurred as headings. The majority of the subcategories corresponded to the legal requirements of the PDA. The legal requirements that referred to patient rights did not have any corresponding subcategory. Subcategories that were found and that concerned goals to be attained and intervention outcomes were not explicitly expressed as legal requirements in the PDA

Keyword
Documentation, Electronic Health Records, Legislation, Qualitative content analysis
National Category
Other Medical Sciences not elsewhere specified
Research subject
Medical Science
Identifiers
urn:nbn:se:uu:diva-246852 (URN)000359655800009 ()
Available from: 2015-03-11 Created: 2015-03-11 Last updated: 2017-12-04Bibliographically approved
2. Predefined headings in a multiprofessional electronic health record system
Open this publication in new window or tab >>Predefined headings in a multiprofessional electronic health record system
2012 (English)In: JAMIA Journal of the American Medical Informatics Association, ISSN 1067-5027, E-ISSN 1527-974X, Vol. 19, no 6, 1032-1038 p.Article in journal (Refereed) Published
Abstract [en]

BackgroundApplying 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.ObjectiveTo study predefined headings applied by users in a Swedish multiprofessional EHR system.Materials and methodsThis 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.ResultsLess 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".DiscussionThe indicated presence of profession-specific predefined headings and the conflict between ambiguity and comprehension of terms and words used as headings are discussed.ConclusionsThe 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.

Keyword
Medical records, Health occupations, Terminology, Documentation
National Category
Other Medical Sciences not elsewhere specified
Research subject
Medical Science
Identifiers
urn:nbn:se:uu:diva-178044 (URN)10.1136/amiajnl-2012-000855 (DOI)000310408500017 ()22744962 (PubMedID)
Available from: 2012-07-24 Created: 2012-07-24 Last updated: 2017-12-07Bibliographically approved

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