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Zhou L, Collins S, Morgan SJ, et al. A Decade of Experience in Creating and Maintaining Data Elements for Structured Clinical Documentation in EHRs. AMIA Annu Symp Proc. 2017;2016:1293-1302
Zhou, L., Collins, S., Morgan, S. J., Zafar, N., Gesner, E. J., Fehrenbach, M., & Rocha, R. A. (2016). A Decade of Experience in Creating and Maintaining Data Elements for Structured Clinical Documentation in EHRs. AMIA ... Annual Symposium proceedings. AMIA Symposium, 20161293-1302.
Zhou, Li, et al. "A Decade of Experience in Creating and Maintaining Data Elements for Structured Clinical Documentation in EHRs." AMIA ... Annual Symposium proceedings. AMIA Symposium vol. 2016 (2016): 1293-1302.
Zhou L, Collins S, Morgan SJ, Zafar N, Gesner EJ, Fehrenbach M, Rocha RA. A Decade of Experience in Creating and Maintaining Data Elements for Structured Clinical Documentation in EHRs. AMIA Annu Symp Proc. 2017 Feb 10;2016:1293-1302. eCollection 2016. PMID: 28269927; PMCID: PMC5333263.
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AMIA Annu Symp Proc. 2017 Feb 10;2016:1293-1302. eCollection 2016.

A Decade of Experience in Creating and Maintaining Data Elements for Structured Clinical Documentation in EHRs.

AMIA ... Annual Symposium proceedings. AMIA Symposium

Li Zhou, Sarah Collins, Stephen J Morgan, Neelam Zafar, Emily J Gesner, Martin Fehrenbach, Roberto A Rocha

Affiliations

  1. Clinical Informatics, Partners HealthCare System, Boston, MA; Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
  2. Clinical Informatics, Partners HealthCare System, Boston, MA.
  3. Institute of Medical Biometry and Informatics, Heidelberg University, Germany.

PMID: 28269927 PMCID: PMC5333263

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.

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