Predefined Headings in a Multi-professional Electronic Health Record : Professionals’ Application, Aspects of Health and Health Care and Correspondence to Legal Requirements

Abstract: The overall aim of this thesis was to investigate predefined headings in a Swedish county council multi-professional EHR system in terms of their shared application, what aspects of health and health care they reflected, and their correspondence to legal requirements. An analysis of 3 596 predefined headings, applied to 20 398 104 occasions by eight professional groups, was conducted. Less than 2% of the predefined headings were applied by all eight professional groups, whereas 60% were not shared at all between the professional groups. A classification of the predefined headings revealed that 13% were “Specialist terms”, which were the least ambiguous predefined headings, 46% were “Terms for specific purposes”, which are less ambiguous than the “Common words” (28%), which were the most ambiguous predefined headings according to the sociolinguistic method employed. The remaining predefined headings (13%) were sorted into “Unclassified headings”. A qualitative content analysis of the predefined headings yielded 23 subcategories grouped into five categories: Description of the patient, Health care process, Resources employed, Administrative documentation, and Development and research. A comparison of the 23 subcategories to the Patient Data Act showed, first, that 15 of 23 subcategories corresponded to four legal requirements, second, that there were legal requirements with a focus on patient rights that were not being met, and third, that there were eight subcategories of predefined headings that could not be attributed to the legal provisions of the Patient Data Act. In conclusion, the proportion of shared predefined headings in the EHRs was limited. The predefined headings in the multi-professional EHRs did not constitute a joint language for specific purposes. A meaningful structure comprising categories and subcategories of different aspects of health and health care as reflected in the applied predefined headings was identified. The structure reflected a wide range of health and health care. No subcategory corresponded to the three legal requirements concerning patient rights. Future research should include professionals’ and patients’ understanding of predefined headings, the correspondence of documented notes to predefined headings and how the documentation in the EHR has had an impact on patient safety.