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: Morrison Z, Fernando B, Kalra D, Cresswell K, Sheikh A Tags: J Am Med Inform Assoc Source Type: research
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