title: A Decade of Experience in Creating and Maintaining Data Elements for Structured Clinical Documentation in EHRs.
abstract: Structured clinical documentation is an important component of electronic health records (EHRs) and plays an important role in clinical care, administrative functions, and research activities. Clinical data elements serve as basic building blocks for composing the templates used for generating clinical documents (such as notes and forms). We present our experience in creating and maintaining data elements for three different EHRs (one home-grown and two commercial systems) across different clinical settings, using flowsheet data elements as examples in our case studies. We identified basic but important challenges (including naming convention, links to standard terminologies, and versioning and change management) and possible solutions to address them. We also discussed more complicated challenges regarding governance, documentation vs. structured data capture, pre-coordination vs. post-coordination, reference information models, as well as monitoring, communication and training.
authors.affiliation: Clinical Informatics, Partners HealthCare System, Boston, MA; Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
authors.forename: Li
authors.initials: L
authors.lastname: Zhou
authors.affiliation: Clinical Informatics, Partners HealthCare System, Boston, MA; Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
authors.forename: Sarah
authors.initials: S
authors.lastname: Collins
authors.affiliation: Clinical Informatics, Partners HealthCare System, Boston, MA; Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Morgan
authors.affiliation: Clinical Informatics, Partners HealthCare System, Boston, MA.
authors.forename: Neelam
authors.initials: N
authors.lastname: Zafar
authors.affiliation: Clinical Informatics, Partners HealthCare System, Boston, MA.
authors.forename: Emily J
authors.initials: EJ
authors.lastname: Gesner
authors.affiliation: Institute of Medical Biometry and Informatics, Heidelberg University, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Fehrenbach
authors.affiliation: Clinical Informatics, Partners HealthCare System, Boston, MA; Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
authors.forename: Roberto A
authors.initials: RA
authors.lastname: Rocha
mesh_terms: D065709:Common Data Elements; D004282:Documentation; D057286:Electronic Health Records / Q000458:organization & administration*; D006801:Humans