BACKGROUND: Use of information technology in the health services has not resulted in the benefits hoped for. An important prerequisite for success may be to structure electronic medical records. Is this assumption research-based? MATERIAL AND METHODS: PubMed was searched via Endnote. The search words "medical record (any field) + structured (any field)" resulted in 843 hits and "electronic decision support (any field)" resulted in 824. Titles and abstracts were used to identify relevant articles; titles identified 103 articles and abstracts 70. RESULTS: Research shows that structured electronic medical records can result in quicker data entry, improved quality and records that are useful in daily clinical work. Doctors and nurses prefer structured data entry; electronic nursing records are better and databases with structured electronic patient records can be used on a large scale to develop treatment regimes and quality assurance. Clinical decision support systems integrated into electronic medical records can provide positive cost-effectiveness. Most doctors and nurses understand the importance of such systems. INTERPRETATION: Structured data entry seems to be an important element in successful electronic medical record systems.
BACKGROUND: Use of information technology in the health services has not resulted in the benefits hoped for. An important prerequisite for success may be to structure electronic medical records. Is this assumption research-based? MATERIAL AND METHODS: PubMed was searched via Endnote. The search words "medical record (any field) + structured (any field)" resulted in 843 hits and "electronic decision support (any field)" resulted in 824. Titles and abstracts were used to identify relevant articles; titles identified 103 articles and abstracts 70. RESULTS: Research shows that structured electronic medical records can result in quicker data entry, improved quality and records that are useful in daily clinical work. Doctors and nurses prefer structured data entry; electronic nursing records are better and databases with structured electronic patient records can be used on a large scale to develop treatment regimes and quality assurance. Clinical decision support systems integrated into electronic medical records can provide positive cost-effectiveness. Most doctors and nurses understand the importance of such systems. INTERPRETATION: Structured data entry seems to be an important element in successful electronic medical record systems.