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Coding the presenting problem

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BCS Learning and Development
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03_Kalra_IPC20_3D2 1..9999 Refereed paper A review of the empirical evidence of the value of structuring and coding of clinical information within electronic health records for direct patient care Dipak Kalra PhD FRCGP FBCS Clinical Professor of Health Informatics, Centre for Health Informatics and Multiprofessional Education, University College London, UK Bernard Fernando MBBS MRCS LRCP MSc MBCS Clinical Research Fellow Zoe Morrison MSc MCIM FHEA Research Associate Aziz Sheikh MD MSc FRCGP FRCP Professor of Primary Care Research & Development eHealth Research Group, Centre for Population Health Sciences, The University of Edinburgh, UK Many of the intended benefits of electronic health records (EHRs) rely upon computers automatically processing the information in them. Such benefitsmay include: practitioner-level outcomes such as more con- sistent and complete clinical documentation; improved patient outcomes and better quality health care de- rived from evidence-based and guideline-oriented health care;1,2 more efficient, effective healthcare sys- tems as a result of greater use of computerised decision support (CDS); enhanced workflow management; ABSTRACT Background The case has historically been pre- sented that structured and/or coded electronic health records (EHRs) benefit direct patient care, but the evidence base for this is not well docu- mented. Methods We searched for evidence of direct patient care value from the use of structured and/ or coded information within EHRs. We interro- gated nine international databases from 1990 to 2011. Value was defined using the Institute of Medicine’s six areas for improvement for healthcare systems: effectiveness, safety, patient-centredness, timeliness, efficiency and equitability. We included studies satisfying the Cochrane Effective Practice and Organisation of Care (EPOC) group criteria. Results Of 5016 potentially eligible papers, 13 studies satisfied our criteria: 10 focused on effec- tiv

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