Electronic Clinical Documentation with Clinical Decision Support

Electronic Clinical Documentation with Clinical Decision Support

Introduction

The U.S. health care industry is being pushed by the National initiatives to embrace electronic health records (EHRs) and make them available for all Americans by the year 2014 (Collins, 2005). The term electronic health record is an umbrella term encompassing both electronic medical records (EMRs), used and maintained by health care providers, and personal health records (PHRs) maintained by consumers. Google Health and Microsoft Health Vault are examples of PHR tools, enabling lay persons to maintain an electronic record of their personal health.

Data-Based Literature Review

Family health information is an important component of EHRs, including family history, next of kin, living situation, whom to notify in case of emergency, and support persons. Family health history information in particular has become of increasing interest in recent years as a result of the expansion of genomic knowledge and the realization that most if not all disease, especially common and chronic disease arises from a combination of multiple genetic and environmental factors (Henley, 2008). Because family members generally share genetic and environmental factors (including behaviors) related to health, family health history provides insight into how these factors interact to result in health and disease states. EHRs hold the promise of making that information easier to maintain, analyze, and apply.

The usefulness of family health history in clinical practice is limited by the time required to collect and to analyze family health history information. EHRs may eventually address these concerns. Collecting the information may be facilitated by enabling consumers and multiple providers to directly contribute information to an electronic record of one's family health history. Additionally, a family health history could be assembled from a variety of existing sources by an EHR system. EHR systems may also facilitate automated analysis of family health history or computer-based scanning of family health histories for provocative patterns (Henley, 2008). This entry describes the current state of family health information in EHRs and explores possible forthcoming innovations.

Family Health Information and Electronic Medical Records

A group of stakeholders from federal health service agencies and the private sector recently convened to define a family health history minimum data set, the core elements of family health history that should be included in EMRs used in primary care settings (Tuohy, 2003). The group envisioned that standardizing representation, including the creation of a minimum data set, will facilitate communication and reuse of family health history data to improve personal health and to build knowledge. The core data elements identified by the group include common elements of family history, such as information pertaining to first- and second-degree relatives, consanguinity, adoptive status, diagnoses and causes of death, and presence or known absence of genetic mutations.

Most EMRs are equipped to maintain most if not all of the information identified in the family health history minimum data set (Tuohy, 2003). EMR systems often include specialized online forms for collection and maintenance of family health history information. These forms are generally to be completed by providers, often while interviewing ...