title: Impacts of structuring the electronic health record: a systematic review protocol and results of previous reviews.
abstract: OBJECTIVE
  This paper (1) presents the protocol of an on-going systematic literature review on the methods of structuring electronic health record (EHR) data and studying the impacts of implemented structures, thus laying basis for the analysis of the empirical articles (2) describes previous reviews published on the subject and retrieved during the search of bibliographic databases, and (3) presents a summary of the results of previous reviews.
  
  
  METHODS
  Cochrane instructions were exploited to outline the review protocol - phases and search elements. Test searches were conducted to refine the search. The abstracts and/or full texts of review papers captured by the search were read by two of the team members independently, with disagreements first negotiated between them and if necessary eventually resolved in the team meetings. Additional review articles were picked from the reference lists of the reviews included in our search results. The elements defined in the search strategy and analytic framework were converted to a data extraction tool, which was tested by extracting data from the reviews captured by the search. Descriptive analysis of the extracted data was conducted.
  
  
  RESULTS
  The 12-stage review protocol that we developed includes definition of the problem, the search strategy and search terms, testing the strategy, conducting the search, updating search from references found, removing duplicates, defining the inclusion and exclusion criteria, exclusion and inclusion of papers, definition of the analytic framework to extract data, extracting data and reporting results. Our searches in fifteen electronic bibliographic databases retrieved 27 reviews, of which 14 were included for full text analysis. Of these, 11 focused on medical and three on nursing record structures. The data structures included forms, ontologies, classifications and terminologies. Some evidence was found on data structure impact on information quality, process quality and efficiency, but not on patients or professionals.
  
  
  CONCLUSIONS
  The 12 step review protocol resulted in a variety of reviews of different ways to structure EHR data. None of them compared outcomes of different structuring methods; all had a narrower definition of the Intervention (a specific EHR structure) and Outcome (a specific impact category). Several reviews missed a clear connection between the data structures (interventions) and outcomes, indicating that the methods and applications for structuring patient data have rarely been viewed as independent variables. The review protocol should be defined in a manner that allows replication of the review. There are different ways of structuring patient data with varying impacts, which should be distinguished in further empirical studies, as well as reviews.
authors.affiliation: Institute for Health and Welfare (THL), Department of Information, PB 30, 00271 Helsinki, Finland. Electronic address: hannele.hypponen@thl.fi.
authors.forename: Hannele
authors.initials: H
authors.lastname: Hyppönen
authors.affiliation: University of Eastern Finland, Finland.
authors.forename: Kaija
authors.initials: K
authors.lastname: Saranto
authors.affiliation: Institute for Health and Welfare (THL), Department of Information, PB 30, 00271 Helsinki, Finland.
authors.forename: Riikka
authors.initials: R
authors.lastname: Vuokko
authors.affiliation: Institute for Health and Welfare (THL), Department of Information, PB 30, 00271 Helsinki, Finland.
authors.forename: Päivi
authors.initials: P
authors.lastname: Mäkelä-Bengs
authors.affiliation: Institute for Health and Welfare (THL), Department of Information, PB 30, 00271 Helsinki, Finland.
authors.forename: Persephone
authors.initials: P
authors.lastname: Doupi
authors.affiliation: Institute for Health and Welfare (THL), Department of Information, PB 30, 00271 Helsinki, Finland.
authors.forename: Minna
authors.initials: M
authors.lastname: Lindqvist
authors.affiliation: Institute for Health and Welfare (THL), Service System Department, Finland.
authors.forename: Marjukka
authors.initials: M
authors.lastname: Mäkelä
mesh_terms: D057286:Electronic Health Records / Q000592:standards*; D019983:Guideline Adherence; D006801:Humans; D017063:Outcome Assessment, Health Care; D000078202:Systematic Reviews as Topic
keywords: Data structure; Electronic health records; Information quality; Process quality; Systematic literature review protocol