Literature Review of Patient Record Structures from the Physician's Perspective

Area of Science:

• Health Informatics
• Medical Data Management
• Clinical Information Systems

Background:

• The Finnish Patient Data Repository, a nationwide electronic health record (EHR) system, collects extensive patient data.
• Understanding EHR data structures is crucial for the repository's development and effective data utilization.

Purpose of the Study:

• To systematically review the literature on the use and usefulness of EHR data structures from a physician's perspective.
• To identify how data structures impact patient care documentation and automated data use.

Main Methods:

• A systematic literature review was conducted, focusing on physician use of data structures in the care process.
• Inclusion and exclusion criteria were applied, resulting in 40 reviewed articles.

Main Results:

• Most studies focused on narrow fields and specialist use in secondary care, with many systems in early development.
• Structured data use can enhance data completeness and automated processing, but narrative text remains essential in some applications.
• Conflicting usability results were reported for structured data representations.

Conclusions:

• Research on widespread EHR systems is scarce, limiting generalizability.
• The practical value of the reviewed literature for system design and implementation is currently limited.
• Further research is needed to address the identified gaps in understanding EHR data structure utility.