Predefined headings in a multiprofessional electronic health record system.

Background: Applying multiprofessional electronic health records (EHRs) is expected to improve the quality of patient care and patient safety. Both EHR systems and system users depend on semantic interoperability to function efficiently. A shared clinical terminology comprising unambiguous terms is required for semantic interoperability. Empirical studies of clinical terminology, such as predefined headings, in EHR systems are scarce and limited to one profession or one clinical specialty.

Objective: To study predefined headings applied by users in a Swedish multiprofessional EHR system.

Materials And Methods: This was a descriptive study of predefined headings (n=3596) applied by 5509 users in a Swedish multiprofessional EHR system. The predefined headings were classified into four term and word categories.

Results: Less than half of the predefined headings were shared by two or more professional groups. All eight professionals groups shared 1.7% of the predefined headings. The distribution of predefined headings across categories yielded two-thirds "terms for special purposes" and "specialist terms" and one-third "common words" and "unclassified headings".

Discussion: The indicated presence of profession-specific predefined headings and the conflict between ambiguity and comprehension of terms and words used as headings are discussed.

Conclusions: The predefined headings in the multiprofessional EHR system studied did not constitute a joint language for specific purposes. The improvement of the quality and usability of multiprofessional EHR systems requires attention.