Structuring the Electronic Patient Record; an Easy Way to Improve Data Usability?

• Main Authors: Silsand, Line, Severinsen, Gro-Hilde, Pedersen, Rune
• Format: Text
• Language: English
• Published: European Society for Socially Embedded Technologies (EUSSET) 2021
• Subjects: Norway; North Norway
• Online Access: https://dx.doi.org/10.18420/ihc2021_008; https://dl.eusset.eu/handle/20.500.12015/4193

In this paper, a qualitative trailing research approach is used, combined with information infrastructure theory to conduct a formative evaluation on an empirical project in North Norway. In this project parts of the clinical information in the electronic health record (EHR) were structured as openEHR archetypes to enable automatic reuse of data from the EHR system to a national medical quality registry. We explore the design- challenges when structuring clinical information for different purposes. Hence, we ask the following research question: What are the premises for reusing clinical information for both primary and secondary purposes? The paper aim to contribute with empirical results and discuss the importance of understanding the prerequisites and implications of reusing clinical information for a duality of purposes. As results we outline three important issues to address. 1) the demand for attaching context when reusing variables, 2) how to ensure reusing the right data, and 3) the challenges of granulating the variables. Lessons learned indicates that governance and competence are the most important prerequisites for improving data usability by structuring clinical information.