title: Building a common ground on the clinical case: design, implementation and evaluation of an information model for a Handover EHR.
abstract: Handovers need a common ground on the clinical cases between the members of the successive shifts to establish continuity of care. Conventional electronic patient record systems (EHR) proved to be only insufficiently suitable for supporting the grounding process. Against this background we proposed a basic concept for a handover EHR that extends general EHRs in particular openEHR based systems. The resulting handover information model was implemented in a database and evaluated based on 120 clinical cases. The information items of these cases could be mapped successfully to the model, however, the new class "anticipatory guidance" needed to be introduced. The evaluation also demonstrated the importance of highly aggregated information on the clinical case, opinions and meta-information such as the relevance of an item during handovers. Based on these findings, in particular the handover database, handover EHR applications are currently developed to support the grounding process.
authors.affiliation: Health Informatics Research Group, University of Applied Science, Osnabrück, Germany.
authors.forename: Daniel
authors.initials: D
authors.lastname: Flemming
authors.affiliation: Health Informatics Research Group, University of Applied Science, Osnabrück, Germany.
authors.forename: Mareike
authors.initials: M
authors.lastname: Paul
authors.affiliation: Health Informatics Research Group, University of Applied Science, Osnabrück, Germany.
authors.forename: Ursula
authors.initials: U
authors.lastname: Hübner
mesh_terms: D057286:Electronic Health Records / Q000458:organization & administration*; D006747:Hospital Communication Systems / Q000458:organization & administration*; D016247:Information Storage and Retrieval / Q000379:methods*; D008498:Medical Record Linkage / Q000379:methods*; D017146:Models, Organizational; D020380:Needs Assessment; D062209:Patient Handoff / Q000458:organization & administration*; D010360:Patient Transfer / Q000458:organization & administration*