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Benefits and risks of structuring and/or coding the presenting patient history in the electronic health record: systematic review
  1. Bernard Fernando1,
  2. Dipak Kalra2,
  3. Zoe Morrison1,
  4. Emma Byrne1,
  5. Aziz Sheikh1
  1. 1eHealth Research Group, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
  2. 2Centre for Health Informatics and Multiprofessional Education, University College London, London, UK
  1. Correspondence to Professor Aziz Sheikh, Professor of Primary Care Research & Development, eHealth Research Group, Centre for Population Health Sciences, University of Edinburgh, Edinburgh EH8 9AG, UK; aziz.sheikh{at}ed.ac.uk

Abstract

Background Patient histories in electronic health records currently exist mainly in free text format thereby limiting the possibility that decision support technology may contribute to the accuracy and timeliness of clinical diagnoses. Structuring and/or coding make patient histories potentially computable.

Methods A systematic review was undertaken of the benefits and risks of structuring and/or coding patient history by searching nine international databases for published and unpublished studies over the period 1990–2010. The focus was on the current patient history, defined as information reported by a patient or the patient's caregiver about the patient's present health situation and health status. Findings were synthesised through a theoretically based textural analysis.

Findings Of the 9207 potentially eligible papers identified, 10 studies satisfied the eligibility criteria. There was evidence of a modest number of benefits associated with structuring the current patient history, including obtaining more complete clinical histories, improved accuracy of patient self-documented histories, and better associated decision-making by professionals. However, no studies demonstrated any resulting improvements in patient care or outcomes. When more detailed records were obtained through the use of a structured format no attempt was made to confirm if this additional information was clinically useful. No studies investigated possible risks associated with structuring the patient history. No studies examined coding of the patient history.

Conclusions There is an insufficient evidence base for sound policy making on the benefits and risks of structuring and/or coding patient history. The authors suggest this field of enquiry warrants further investigation given the interest in use of decision support technology to aid diagnoses.

  • Clinical coding
  • electronic health records
  • patient history
  • structured data entry
  • medication safety
  • information technology
  • decision support, computerised
  • decision support, clinical
  • diagnostic errors
  • patient safety
  • medical error
  • primary care

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Footnotes

  • Funding This work was funded by the NHS CFH Evaluation Programme (NHS CFHEP 009). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NHS CFH Evaluation Programme or the Department of Health.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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