Definition, structure, content, use and impacts of electronic health records: A review of the research literature

Abstract

Purpose

This paper reviews the research literature on electronic health record (EHR) systems. The aim is to find out (1) how electronic health records are defined, (2) how the structure of these records is described, (3) in what contexts EHRs are used, (4) who has access to EHRs, (5) which data components of the EHRs are used and studied, (6) what is the purpose of research in this field, (7) what methods of data collection have been used in the studies reviewed and (8) what are the results of these studies.

Methods

A systematic review was carried out of the research dealing with the content of EHRs. A literature search was conducted on four electronic databases: Pubmed/Medline, Cinalh, Eval and Cochrane.

Results

The concept of EHR comprised a wide range of information systems, from files compiled in single departments to longitudinal collections of patient data. Only very few papers offered descriptions of the structure of EHRs or the terminologies used. EHRs were used in primary, secondary and tertiary care. Data were recorded in EHRs by different groups of health care professionals. Secretarial staff also recorded data from dictation or nurses’ or physicians’ manual notes. Some information was also recorded by patients themselves; this information is validated by physicians. It is important that the needs and requirements of different users are taken into account in the future development of information systems.

Several data components were documented in EHRs: daily charting, medication administration, physical assessment, admission nursing note, nursing care plan, referral, present complaint (e.g. symptoms), past medical history, life style, physical examination, diagnoses, tests, procedures, treatment, medication, discharge, history, diaries, problems, findings and immunization. In the future it will be necessary to incorporate different kinds of standardized instruments, electronic interviews and nursing documentation systems in EHR systems.

The aspects of information quality most often explored in the studies reviewed were the completeness and accuracy of different data components. It has been shown in several studies that the use of an information system was conducive to more complete and accurate documentation by health care professionals. The quality of information is particularly important in patient care, but EHRs also provide important information for secondary purposes, such as health policy planning.

Conclusion

Studies focusing on the content of EHRs are needed, especially studies of nursing documentation or patient self-documentation. One future research area is to compare the documentation of different health care professionals with the core information about EHRs which has been determined in national health projects. The challenge for ongoing national health record projects around the world is to take into account all the different types of EHRs and the needs and requirements of different health care professionals and consumers in the development of EHRs. A further challenge is the use of international terminologies in order to achieve semantic interoperability.

Introduction

Research and development projects are ongoing in several countries around the world to develop an infrastructure for national health information; examples include Canada [1], Australia [2], England [3], the United States [4] and Finland [5]. These projects share in common a number of elements, including (1) the aim of involving patients in the use of their own health records; (2) the need to define the core information of these records; (3) the choice and implementation of standards, nomenclatures, codes and vocabularies; (4) the need to develop the necessary data security infrastructure and policies; (5) the aim of producing open, standardized and interoperable EHR systems for data exchange and information management. Besides national projects, the European Union launched the European eHealth Action Plan in 2004. One challenge is to standardize health information systems, which also means standardization of the content and structure of EHRs [6]. In particular, a patient summary has been seen as the most appropriate way to establish eHealth interoperability. A patient summary includes patient history, allergies, active problems, test results, and medications. However, further information can be included, depending on the intended purpose of the summary and the anticipated context of use. Additionally, investigation into the amount of structured data of the patient summary is needed [7]. EHRs are a major focus for current research in the field of health informatics [8], [9] but the need for research from different approaches has also been noticed [10] The focus of recent studies concerning EHR has been on the possibilities of current technologies and underlying architecture (cf. [11], [12], [13]) and on exploring the health care registers as a source for evidence-based medicine [14].

According to the literature, the meaning of EHR is unstable. EHR has many functions and includes many kinds of data, and it is obvious that there is a need to determine explicitly what EHR means. Once that has been done, common ways to develop EHRs will be found, along with common viewpoints on what kind of research focusing on the content of EHR can be done in the future. The aim of this study is to determine what an electronic health record is and how far its content is standardized. An EHR is used primarily for purposes of setting objectives and planning patient care, documenting the delivery of care and assessing the outcomes of care. It includes information regarding patient needs during episodes of care provided by different health care professionals [15], [16]. The amount and quality of information available to health care professionals in patient care has an impact both on the outcomes of patient care and the continuity of care. The information included in EHRs has several different functions in the decision-making process in patient care, and it also supports decision-making in management and in health policy. EHRs have so far consisted of unstructured, narrative text but also structured coded data. In the future it will be necessary to implement more systematic terminologies and codes so that the data contained in these records can be put to better use in clinical research, health care management, health services planning, and government reporting [8], [9], [15], [16]. Thiru et al. have reviewed the literature assessing the quality of data in EHRs in primary care. They report that the main focus has been on structured data elements, i.e. codes, classifications and nomenclatures. Most of the studies included in their review were descriptive surveys. Thiru et al. also draw attention to the lack of standardized methods for the assessment of data quality [17].

The present review focuses on research that is concerned with the structure and content of EHR systems. It aims to answer the following questions: (1) how is the EHR defined in earlier research, (2) how is the structure of EHRs described, (3) in which contexts is the EHR used, (4) who has access to EHRs, (5) what data components of the record system are used by end-users and studied, (6) what is the purpose of these studies, (7) what methods of data collection are used in the studies and (8) what are the results of these studies.