Work

Clinical Summarization Capabilities of Commercially-available and Internally-developed Electronic Health Records

Year: 2012

Type: article

Abstract: OBJECTIVE: Clinical summarization, the process by which relevant patient information is electronically summarized and presented at the point of care, is of increasing importance given the increasing volume of clinical data in electronic health record systems (EHRs). There is a paucity of research on electronic clinical summarization, including the capabilities of currently available EHR systems. METHODS: We compared different aspects of general clinical summary screens used in twelve different EHR systems using a previously described conceptual model: AORTIS (Aggregation, Organization, Reduction, Interpretation and Synthesis). RESULTS: We found a wide variation in the EHRs' summarization capabilities: all systems were capable of simple aggregation and organization of limited clinical content, but only one demonstrated an ability to synthesize information from the data. CONCLUSION: Improvement of the clinical summary screen functionality for currently available EHRs is necessary. Further research should identify strategies and methods for creating easy to use, well-designed clinical summary screens that aggregate, organize and reduce all pertinent patient information as well as provide clinical interpretations and synthesis as required.

Source: Applied Clinical Informatics

DOI: 10.4338/aci-2011-11-ra-0066

Authors: A. Laxmisan, A. B. McCoy, A. Wright, D. F. Sittig

Institutions: Michael E. DeBakey VA Medical Center, Baylor College of Medicine, The University of Texas Health Science Center at Houston, Brigham and Women's Hospital, Harvard University

Language: English

Topic: Electronic Health Records Systems

Subfield: Health Information Management

Field: Health Professions

Domain: Health Sciences

SDG: Good health and well-being

Open Access status: green

Funder: U.S. National Library of Medicine