Structuring Electronic Patient Record Data, a Smart Way to Extract Registry Information?

Abstract

The paper reports from one of the first efforts to generate data for a national register by automatically reusing data recorded in the clinical documentation process. Today, the process of reporting to national registries implies filling out a paper-based or electronic form as the final step of documenting patients’ treatment. The registries’ forms are hence not part of the patients’ Electronic Patient Record (EPR). Therefore, the Norwegian Directorate for e-health has established a program for developing a shared infrastructure for 51 national registers, aiming to improve the utilization and quality of the reported health data. We argue that the quality of the registries’ data rests heavily on an understanding of today’s practice and how and when to capture the data. This paper describes the initial work of facilitating automatic reuse of standardized clinical data recorded from the EPR to the Norwegian registry for spine surgery. The empirical setting is the regional FRESK (Future systems in the clinic) program (2017-2022), in the North Norwegian Health Region.