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From Free-Text to Structure in Electronic Patient Records
Gro-Hilde Severinsen1, Line Silsand1, Gunnar Ellingsen1,2
1Norwegian Center for E-health Research - University Hospital North Norway.
Studies in Health Technology and Informatics
|August 22, 2019
Summary
Transitioning from free-text to structured electronic patient record (EPR) systems presents legislative and interoperability challenges. Addressing these is key for advanced clinical decision support and healthcare data reuse.
Area of Science:
- Health Informatics
- Information Systems Research
- Qualitative Research Methods
Background:
- Healthcare data management is shifting from free-text electronic patient record (EPR) systems to structured formats.
- This transition is crucial for enabling advanced clinical decision support and data reuse.
- Current EPR systems often exist in silos, hindering seamless data exchange.
Purpose of the Study:
- To explore challenges in transitioning from free-text to structured EPR systems.
- To investigate the impact of semantic interoperability on clinical decision support.
- To identify practical and legislative hurdles in EPR system migration.
Main Methods:
- Qualitative action research approach.
- Collaboration between two post-doctoral projects.
- Empirical data from the FRESK program (North Norwegian Health Region, 2017-2022).
Main Results:
- Exploration of legislative challenges in accessing healthcare data.
- Analysis of data exchange issues between siloed and open platform systems.
- Investigation into practical challenges of defining structured EPR content during system replacement.
Conclusions:
- Addressing legislative and interoperability challenges is vital for successful EPR system migration.
- Semantic interoperability significantly influences the potential for advanced clinical decision support.
- The shift requires careful consideration of data access, exchange, and content definition.
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