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The development of clinically structured entry systems seems to be the optimal solution, which can preformat information into predefined section fields.
- 'Why do existing ambulatory EHRs still not allow for the structured entry of medical data?' - PHC physician.
The modeling of free text annotations in the tree structure, enabling the author to describe in his own words a concept or a finding, is an example of a (partial) concession made to the structured entry of data.
Vanderbilt University Medical Center (VUMC) in Nashville, TN, USA, has developed a clinical interface terminology for use in its EHR system components, including a structured entry tool designed to support clinical documentation.
Recently promulgated federal regulations for "meaningful use" of electronic health records mandate that physicians must document a coded problem (or a structured entry indicating that the patient has no problems) for at least 80% of their patients in order to qualify for substantial incentive payments.
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A central question facing education policymakers is how to structure entry pathways into teaching.
An expandable EMR system with structured data entry (OpenSDE) for pediatrics was developed, allowing structured documentation of patient history and physical examination.
The template would then help structured data entry of other related symptoms, including important negative findings.
EMR: electronic medical record SDE: structured data entry The author(s) declare that they have no competing interests.
Structured data entry is essential for all forms of interactive, clinical decision support, as well as the most difficult aspect of EHRs for clinicians to adopt.
Although it's partly like what the Julius Template Service does, their focus wasn't to share EHR data but the screen templates used for structured data entry.
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