A Decade of Experience in Creating and Maintaining Data Elements for Structured Clinical Documentation in EHRs

Area of Science:

• Health Informatics
• Clinical Data Management
• Electronic Health Records (EHRs)

Background:

• Structured clinical documentation is vital for EHRs, supporting clinical care, administration, and research.
• Clinical data elements are fundamental components for creating templates in clinical notes and forms.
• Effective data element management impacts the overall utility and integrity of health information systems.

Purpose of the Study:

• To share experiences in creating and maintaining data elements across diverse EHR systems and clinical settings.
• To identify and propose solutions for common challenges in clinical data element management.
• To explore complex issues including governance, data capture strategies, and terminology coordination.

Main Methods:

• Case studies using flowsheet data elements from three different EHRs (one in-house, two commercial).
• Analysis of challenges encountered during data element creation and maintenance.
• Discussion of potential solutions and best practices.

Main Results:

• Identified key challenges: naming conventions, linking to standard terminologies, and version/change management.
• Highlighted complex issues: governance, documentation vs. structured data, pre- vs. post-coordination, reference models, and training.
• Demonstrated the need for systematic approaches to data element management.

Conclusions:

• Effective management of clinical data elements requires addressing both basic and complex challenges.
• Standardization in naming, terminology, and versioning is essential for data consistency.
• Robust governance and training are critical for successful EHR data element implementation and use.