title: National evaluation of the benefits and risks of greater structuring and coding of the electronic health record: exploratory qualitative investigation.
abstract: OBJECTIVE
  We aimed to explore stakeholder views, attitudes, needs, and expectations regarding likely benefits and risks resulting from increased structuring and coding of clinical information within electronic health records (EHRs).
  
  
  METHODS
  Qualitative investigation in primary and secondary care and research settings throughout the UK. Data were derived from interviews, expert discussion groups, observations, and relevant documents. Participants (n=70) included patients, healthcare professionals, health service commissioners, policy makers, managers, administrators, systems developers, researchers, and academics.
  
  
  RESULTS
  Four main themes arose from our data: variations in documentation practice; patient care benefits; secondary uses of information; and informing and involving patients. We observed a lack of guidelines, co-ordination, and dissemination of best practice relating to the design and use of information structures. While we identified immediate benefits for direct care and secondary analysis, many healthcare professionals did not see the relevance of structured and/or coded data to clinical practice. The potential for structured information to increase patient understanding of their diagnosis and treatment contrasted with concerns regarding the appropriateness of coded information for patients.
  
  
  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.
authors.affiliation: eHealth Research Group, Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK.
authors.forename: Zoe
authors.initials: Z
authors.lastname: Morrison
authors.forename: Bernard
authors.initials: B
authors.lastname: Fernando
authors.forename: Dipak
authors.initials: D
authors.lastname: Kalra
authors.forename: Kathrin
authors.initials: K
authors.lastname: Cresswell
authors.forename: Aziz
authors.initials: A
authors.lastname: Sheikh
mesh_terms: D001291:Attitude of Health Personnel; D001294:Attitude to Health; D059019:Clinical Coding; D057286:Electronic Health Records / Q000458:organization & administration*; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D005791:Patient Care; D010564:Personnel, Hospital; D036301:Qualitative Research; D012051:Reimbursement Mechanisms; D013222:State Medicine / Q000458:organization & administration*; D006113:United Kingdom
keywords: Clinical Coding; Data Structure; Electronic Health Records; Electronic Patient Records; Patient Communication