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Reflections on the use of electronic health record data for clinical research

RTI International 3040 Cornwallis Road PO Box 12194, Research Triangle Park NC 27709-2194, USA, swest{at}rti.org

Catherine Blake

School of Information and Library Science University of North Carolina Chapel Hill, NC 27599-3360, USA,

Zhiwen Liu

epartment of Epidemiology School of Public Health University of North Carolina Chapel Hill, NC 27599-7435, USA

J. Nikki McKoy

Institute for Medicine and Public Health Vanderbilt University Nashville, TN 37203-1738, USA

Maryann D. Oertel

Drug Information Services Department of Pharmacy UNC Hospitals Chapel Hill, NC 27599-7600, USA

Timothy S. Carey

Cecil G. Sheps Center for Health Services Research University of North Carolina Chapel Hill, NC 27599-7590, USA

The adoption of electronic health records (EHRs) offers the potential to improve the delivery, quality, and continuity of clinical care, but widespread use has not yet occurred. In this article, we describe our use of clinical (production) data that were derived from outpatient and inpatient visits at a university teaching hospital for clinical research, a use for which the data and their structure were not originally designed. Similar data exist at many outpatient and inpatient clinical facilities, and we believe that our insights are relevant to electronically captured medical data regardless of their origin. We describe the approaches taken to ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA) and to leverage the vast stores of structured and unstructured data that are currently underused. We conclude by reflecting on what we would have done differently and by making recommendations to streamline the process.

Key Words: computerized medical records systems • confidentiality • electronic health record • HIPAA

Health Informatics Journal, Vol. 15, No. 2, 108-121 (2009)
DOI: 10.1177/1460458209102972


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