National evaluation of the benefits and risks of greater structuring and coding of the electronic health record: exploratory qualitative investigation.

CONCLUSIONS: The design and development of EHRs requires the capture of narrative information to reflect patient/clinician communication and computable data for administration and research purposes. Increased structuring and/or coding of EHRs therefore offers both benefits and risks. Documentation standards within clinical guidelines are likely to encourage comprehensive, accurate processing of data. As data structures may impact upon clinician/patient interactions, new models of documentation may be necessary if EHRs are to be read and authored by patients. PMID: 24186957 [PubMed - as supplied by publisher]
Source: Journal of the American Medical Informatics Association - Category: Information Technology Authors: Tags: J Am Med Inform Assoc Source Type: research