From free-text to a structured Electronic Health Record – the preconditions for clinical decision support

Description

This project aims to address socio-technical challenges when structuring clinical information in electronic health records (EHR), to enable sharing and reusing clinical data for primarily clinical use and secondary use like national registries and research. Structuring and reusing EHR data is of importance to support the goals of the Whitepaper no. 9 “One citizen - one record”.

In an overall perspective the EHR is considered to be key to e-health collaboration in the future, in terms of enabling updated clinical information that is shared amongst healthcare personnel, as well as communication between patients and healthcare personnel. Sharing and reusing clinical information addresses the need for structured data to enable that the right information is correctly reused at the right time.

To that end, an infrastructure based on structured clinical information will underline safe patient pathways where digital decision support (alerts, available information, guidelines etc.) is integrated as part of the EHR. In spite of high expectations to the impact of implementing structured EHR solutions regionally, nationally and internationally, knowledge about how to structure the EHR for primary and secondary purposes is very limited. Previous studies about implementing new clinical ICT systems in general, illustrate that the main challenges to achieving the expected effects of the new technology relate to the need for reorganization of work processes in different organizations.

The main objective of the project is to provide systematic knowledge about how structuring clinical information must be conducted to support safe patient pathways, communication between patients and healthcare personnel, as well as high quality clinical practice.

Goals

1. Exploit how clinical information must be structured to cover both primary and secondary purposes.
2. Address how structured clinical information can support information flow in patient pathways.
3. Discuss socio-technical challenges related to structuring clinical information for primary and secondary purposes.
4. Present knowledge on how structured clinical information must be conducted to support safe patient pathways, communication between patients and healthcare personnel, as well as high quality clinical practice.

Method

We will use a project action research approach. Formative action research demands for close collaboration between researchers and the empirical field; where researchers discussing findings and ongoing analyses of the process with involved representatives from the field. This qualitative data collection includes participatory observations, semi-structured interviews and document studies in all phases of the project to gain an overall understanding of the field

Empirically the project follows the regional implementations of clinical ICT systems (FRESK) in Helse Nord, focusing on the empirical work with structuring and implementing the new openEHR based EHR system DIPS Arena.