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Appl Clin Inform 2014; 05(02): 402-415
DOI: 10.4338/ACI-2013-12-RA-0101
Research Article
Schattauer GmbH

An Analysis of Free-Text Alcohol Use Documentation in the Electronic Health Record

Early Findings and Implications
ES Chen
1   Biomedical Informatics Unit – Center for Clinical and Translational Science, University of Vermont, Burlington, VT
2   Division of General Internal Medicine – Department of Medicine, University of Vermont, Burlington, VT
3   Department of Computer Science, University of Vermont, Burlington, VT
,
M. Garcia-Webb
4   University of Massachusetts Medical School, Worcester, MA
› Author Affiliations
Further Information

Publication History

Received: 16 December 2013

Accepted: 25 February 2014

Publication Date:
21 December 2017 (online)

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Summary

Background: Alcohol use is a significant part of a patient’s history, but details about consumption are not always documented. Electronic Health Record (EHR) systems have the potential to improve assessment of alcohol use and misuse; however, a challenge is that critical information may be documented primarily in free-text rather than in a structured and standardized format, thereby limiting its use.

Objective: To characterize the use and contents of free-text documentation for alcohol use in the social history module of an EHR.

Methods: This study involved a retrospective analysis of 500 alcohol use entries that include structured fields as well as a free-text comment field. Two coding schemes were developed and used to analyze these entries for: (1) quantifying the reasons for using free-text comments and (2) categorizing information in the free-text into separate elements. In addition, for entries indicating possible alcohol misuse, a preliminary review of other structured parts of the EHR was conducted to determine if this was also documented elsewhere.

Results: The top three reasons for using free-text were limited ability to describe alcohol use frequency (75%), amount (22%), and status (18%) with available structured fields. Within the free-text, descriptions of frequency were most common (79%) using words or phrases conveying occasional (61%), daily (13%), or weekly (12%) use. Of the 36 cases suggesting alcohol misuse, 44% had mention of alcohol problems in the problem list or past medical history.

Conclusions: Based on the early findings, implications for improving the structured collection and use of alcohol use information in the EHR are provided in four areas: (1) system enhancements, (2) user training, (3) decision support, and (4) standards. Next steps include examining how alcohol use is documented in other parts of the EHR (e.g., clinical notes) and how documentation practices vary based on patient, provider, and clinic characteristics.

Citation: Chen ES, M. Garcia-Webb M. An analysis of free-text alcohol use documentation in the electronic health record: Early findings and implications. Appl Clin Inf 2014; 5: 402–415 http://dx.doi.org/10.4338/ACI-2013-12-RA-0101

Keywords

Alcohol drinking - alcoholism - medical history taking - electronic health records
 

  • References

  • 1 Bouchery EE, Harwood HJ, Sacks JJ, Simon CJ, Brewer RD. Economic costs of excessive alcohol consumption in the U. S., 2006. American journal of preventive medicine 2011; 41 (Suppl. 05) 516-524.
    CrossrefPubMedSearch in Google Scholar
  • 2 Hasin DS, Stinson FS, Ogburn E, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of general psychiatry 2007; 64 (Suppl. 07) 830-842.
    CrossrefPubMedSearch in Google Scholar
  • 3 Eckardt MJ, Harford TC, Kaelber CT, Parker ES, Rosenthal LS, Ryback RS, Salmoiraghi GC, Vanderveen E, Warren KR. Health hazards associated with alcohol consumption. JAMA : the journal of the American Medical Association 1981; 246 (Suppl. 06) 648-66.
    CrossrefPubMedSearch in Google Scholar
  • 4 Bradley KA, Lapham GT, Hawkins EJ, Achtmeyer CE, Williams EC, Thomas RM, Kivlahan DR. Quality concerns with routine alcohol screening in VA clinical settings. Journal of general internal medicine 2011; 26 (Suppl. 03) 299-306.
    CrossrefPubMedSearch in Google Scholar
  • 5 Jaworowski S, Raveh D, Golmard JL, Gropp C, Mergui J. Alcohol use disorder in an Israeli general hospital: sociodemographic, ethnic and clinical characteristics. The Israel Medical Association journal 2012; 14 (Suppl. 05) 294-298.
    PubMedSearch in Google Scholar
  • 6 Callahan CM, Tierney WM. Health services use and mortality among older primary care patients with alcoholism. Journal of the American Geriatrics Society 1995; 43 (12) 1378-1383.
    CrossrefPubMedSearch in Google Scholar
  • 7 Moyer VA, Preventive Services Task F. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U. S. preventive services task force recommendation statement. Annals of internal medicine 2013; 159 (Suppl. 03) 210-218.
    PubMedSearch in Google Scholar
  • 8 National Institute on Alcohol Abuse and Alcoholism.. Helping Patients Who Drink Too Much: A Clinician’s Guide. [December 2013]; Available from: http://www.niaaa.nih.gov/guide.
    PubMed
  • 9 Willenbring ML, Massey SH, Gardner MB. Helping patients who drink too much: an evidence-based guide for primary care clinicians. American family physician 2009; 80 (Suppl. 01) 44-50.
    PubMedSearch in Google Scholar
  • 10 Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Archives of internal medicine 1998; 158 (16) 1789-1795.
    CrossrefPubMedSearch in Google Scholar
  • 11 Babor T, Higgins-Biddle J, Saunders J, Monteiro M. The Alcohol Use Disorders Identification Test Guidelines for Use in Primary Care. 2001 [December 2013]; Available from: http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6a.pdf.
    PubMed
  • 12 Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. Primary care validation of a single-question alcohol screening test. Journal of general internal medicine 2009; 24 (Suppl. 07) 783-788.
    CrossrefPubMedSearch in Google Scholar
  • 13 Friedmann PD. Clinical practice. Alcohol use in adults. The New England journal of medicine 2013; 368 (Suppl. 04) 365-373.
    CrossrefPubMedSearch in Google Scholar
  • 14 Cimino JJ. Improving the electronic health record--are clinicians getting what they wished for?. JAMA : the journal of the American Medical Association 2013; 309 (10) 991-992.
    CrossrefPubMedSearch in Google Scholar
  • 15 Kim HM, Smith EG, Ganoczy D, Walters H, Stano CM, Ilgen MA, Bohnert AS, Valenstein M. Predictors of suicide in patient charts among patients with depression in the Veterans Health Administration health system: importance of prescription drug and alcohol abuse. The Journal of clinical psychiatry 2012; 73 (10) e1269-e1275.
    CrossrefPubMedSearch in Google Scholar
  • 16 Williams EC, Lapham G, Achtmeyer CE, Volpp B, Kivlahan DR, Bradley KA. Use of an electronic clinical reminder for brief alcohol counseling is associated with resolution of unhealthy alcohol use at follow-up screening. Journal of general internal medicine 2010; 25 (Suppl. 01) 11-17.
    CrossrefPubMedSearch in Google Scholar
  • 17 Seppa K, Lahtinen T, Antila S, Aalto M. Alcohol drinking among emergency patients - alcometer use and documentation. Alcohol and alcoholism 2004; 39 (Suppl. 03) 262-265.
    CrossrefPubMedSearch in Google Scholar
  • 18 Torti J, Duerksen K, Forst B, Salvalaggio G, Jackson D, Manca D. Documenting alcohol use in primary care in Alberta. Canadian family physician Medecin de famille canadien 2013; 59 (10) 1128 e473–e474.
    PubMedSearch in Google Scholar
  • 19 Polednak AP. Documentation of alcohol use in hospital records of newly diagnosed cancer patients: a population-based study. The American journal of drug and alcohol abuse 2007; 33 (Suppl. 03) 403-409.
    CrossrefPubMedSearch in Google Scholar
  • 20 Bell J, Kilic C, Prabakaran R, Wang Y, Wilson R, Broadbent M, Kumar A, Curtis V. Use of electronic health recoprds in identifying drug and alcohol misuse among psychiatric in-patients. The Psychiatrist 2013; 37: 15-20.
    CrossrefPubMedSearch in Google Scholar
  • 21 Freedy JR, Ryan K. Alcohol use screening and case finding: screening tools, clinical clues, and making the diagnosis. Primary care 2011; 38 (Suppl. 01) 91-103.
    CrossrefPubMedSearch in Google Scholar
  • 22 Clifford A, Shakeshaft A, Deans C. Training and tailored outreach support to improve alcohol screening and brief intervention in Aboriginal Community Controlled Health Services. Drug and alcohol review 2013; 32 (Suppl. 01) 72-79.
    CrossrefPubMedSearch in Google Scholar
  • 23 Lapham GT, Achtmeyer CE, Williams EC, Hawkins EJ, Kivlahan DR, Bradley KA. Increased documented brief alcohol interventions with a performance measure and electronic decision support. Medical care 2012; 50 (Suppl. 02) 179-187.
    CrossrefPubMedSearch in Google Scholar
  • 24 Middleton B, Renner K, Leavitt M. Ambulatory practice clinical information management: problems and prospects. Healthcare information management : journal of the Healthcare Information and Management Systems Society of the American Hospital Association 1997; 11 (Suppl. 04) 97-112.
    PubMedSearch in Google Scholar
  • 25 Linder JA, Schnipper JL, Middleton B. Method of electronic health record documentation and quality of primary care. Journal of the American Medical Informatics Association 2012; 19 (Suppl. 06) 1019-1024.
    CrossrefPubMedSearch in Google Scholar
  • 26 Zhou L, Mahoney LM, Shakurova A, Goss F, Chang FY, Bates DW, Rocha RA. How many medication orders are entered through free-text in EHRs?--a study on hypoglycemic agents. AMIA Annual Symposium proceedings / AMIA Symposium AMIA Symposium 2012; 2012: 1079-1088.
    PubMedSearch in Google Scholar
  • 27 Friedman C, Hripcsak G. Natural language processing and its future in medicine. Academic medicine : journal of the Association of American Medical Colleges 1999; 74 (Suppl. 08) 890-895.
    CrossrefPubMedSearch in Google Scholar
  • 28 Meystre SM, Savova GK, Kipper-Schuler KC, Hurdle JF. Extracting information from textual documents in the electronic health record: a review of recent research. Yearbook of medical informatics 2008: 128-44.
    PubMed
  • 29 Uzuner O, Goldstein I, Luo Y, Kohane I. Identifying patient smoking status from medical discharge records. Journal of the American Medical Informatics Association 2008; 15 (Suppl. 01) 14-24.
    CrossrefPubMedSearch in Google Scholar
  • 30 Wang SJ, Bates DW, Chueh HC, Karson AS, Maviglia SM, Greim JA, Frost JP, Kuperman GJ. Automated coded ambulatory problem lists: evaluation of a vocabulary and a data entry tool. International journal of medical informatics 2003; 72 1–3 17-28.
    CrossrefPubMedSearch in Google Scholar
  • 31 Zheng K, Hanauer DA, Padman R, Johnson MP, Hussain AA, Ye W, Zhou X, Diamond HS. Handling anticipated exceptions in clinical care: investigating clinician use of ’exit strategies’ in an electronic health records system. Journal of the American Medical Informatics Association 2011; 18 (Suppl. 06) 883-889.
    CrossrefPubMedSearch in Google Scholar
  • 32 Chen ES, Melton GB, Burdick TE, Rosenau PT, Sarkar IN. Characterizing the use and contents of free-text family history comments in the Electronic Health Record. AMIA Annual Symposium proceedings / AMIA Symposium AMIA Symposium 2012; 2012: 85-92.
    PubMedSearch in Google Scholar
  • 33 Fletcher Allen Health Care.. [January 2014]; Available from: http://www.fletcherallen.org.
    PubMed
  • 34 McDowell SW, Wahl R, Michelson J. Herding cats: the challenges of EMR vendor selection. Journal of healthcare information management 2003; 17 (Suppl. 03) 63-71.
    PubMedSearch in Google Scholar
  • 35 Epic Systems Corporation.. [January 2014]; Available from: http://www.epic.com.
    PubMed
  • 36 Chen ES, Manaktala S, Sarkar IN, Melton GB. A multi-site content analysis of social history information in clinical notes. AMIA Annual Symposium proceedings / AMIA Symposium AMIA Symposium 2011; 2011: 227-236.
    PubMedSearch in Google Scholar
  • 37 Melton GB, Manaktala S, Sarkar IN, Chen ES. Social and behavioral history information in public health datasets. AMIA Annual Symposium proceedings / AMIA Symposium AMIA Symposium 2012; 2012: 625-634.
    PubMedSearch in Google Scholar
  • 38 Health Level Seven International (HL7).. [December 2013]; Available from: http://www.hl7.org.
    PubMed
  • 39 Dolin RH, Alschuler L, Boyer S, Beebe C, Behlen FM, Biron PV, Shabo Shvo A. HL7 Clinical Document Architecture, Release 2. Journal of the American Medical Informatics Association 2006; 13 (Suppl. 01) 30-39.
    CrossrefPubMedSearch in Google Scholar
  • 40 openEHR.. [December 2013]; Available from: http://www.openehr.org.
    PubMed
  • 41 openEHR Clinical Knowledge Manager.. [December 2013]; Available from: http://www.openehr.org/ckm.
    PubMed
  • 42 SNOMED Clinical Terms (SNOMED CT).. [December 2013]; Available from: http://www.ihtsdo.org/snomed-ct/.
    PubMed
  • 43 Behavioral Risk Factor Surveillance System.. [December 2013]; Available from: http://www.cdc.gov/brfss.
    PubMed
  • 44 National Health and Nutrition Examination Survey.. [December 2013]; Available from: http://www.cdc/gov/nchs/nhanes.htm
    PubMed
  • 45 National Health Interview Survey.. [December 2013]; Available from: http://www.cdc.gov/nchs/nhis.htm.
    PubMed