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Predefined headings in a multiprofessional electronic health record system.

Annika Terner1, Helena Lindstedt, Karin Sonnander

  • 1Department of Public Health and Caring Sciences, Disability and Habilitation, Uppsala University, Uppsala, Sweden. annika.terner@pubcare.uu.se

Journal of the American Medical Informatics Association : JAMIA
|June 30, 2012
PubMed
Summary

Multiprofessional electronic health records (EHRs) lack a shared clinical terminology, hindering semantic interoperability. Most predefined headings are profession-specific, not a joint language for improving EHR quality and usability.

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Area of Science:

  • Health Informatics
  • Clinical Terminology
  • Electronic Health Records

Background:

  • Electronic health records (EHRs) aim to enhance patient care and safety through multiprofessional application.
  • Semantic interoperability in EHR systems is crucial for efficient functioning and relies on shared clinical terminologies.
  • Empirical studies on clinical terminology within EHR systems are limited, particularly across different professions.

Purpose of the Study:

  • To investigate the predefined headings used by healthcare professionals in a Swedish multiprofessional EHR system.
  • To analyze the extent of shared terminology across different professional groups within the EHR system.

Main Methods:

  • A descriptive study analyzing 3596 predefined headings used by 5509 users in a Swedish multiprofessional EHR system.
  • Classification of predefined headings into four categories: terms for special purposes, specialist terms, common words, and unclassified headings.

Main Results:

  • Less than half of the predefined headings were utilized by more than one professional group.
  • Only 1.7% of headings were shared across all eight professional groups studied.
  • Two-thirds of headings were categorized as 'terms for special purposes' or 'specialist terms', while one-third were 'common words' or 'unclassified'.

Conclusions:

  • The study identified a prevalence of profession-specific headings, indicating a lack of a unified clinical language within the multiprofessional EHR.
  • The ambiguity and comprehension of terms used as headings present challenges for effective communication and data integration.
  • Improving the quality and usability of multiprofessional EHR systems necessitates addressing the limitations in shared terminology.