Conference article

Using a scoping review technique, this paper investigates approaches, challenges, and success factors when adopting highly structured Electronic Health Records (EHRs). Our findings are consistent with previous literature that reports that the most common methods for structuring patient data consist of a combination of codes, terminologies, reference information models, and standards. However, the review identified new factors and challenges previously not considered as critical areas for the successful implementation of highly structured EHRs; challenges related to human factors seem to be of paramount importance for the success of standard-based EHR adoption. The review revealed that main challenges are related to maturity of the technologies; methods for governance of clinical models; slow adoption of standards; high cost of running pilots; lack of standard compliance and validation mechanisms; and unclear terminology binding of information models. Key success factors are the availability of validated Clinical Information Models (CIMs) and value sets; properly leveraging and managing the complex technology stack; rapidly coordinating EHR implementers with governance bodies; performing agile requirements management; involvement of all stakeholders in the development of standard specifications; and implementing early pilots evaluating the adoption of structured EHRs.

Structured EHR, health information standards, terminologies, decision support, review.