ArticleApplied clinical informatics2014
An analysis of free-text alcohol use documentation in the electronic health record: early findings and implications.
Article in Applied clinical informatics, 2014. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 14 papers.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
14 citing papers in PubMed.
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- Automated-detection of risky alcohol use prior to surgery using natural language processing.Alcohol, clinical & experimental research · 2024Article
- Inaccurate recording of routinely collected data items influences identification of COVID-19 patients.International journal of medical informatics · 2022Article
- Factors Influencing Problem List Use in Electronic Health Records-Application of the Unified Theory of Acceptance and Use of Technology.Applied clinical informatics · 2020Article
- Electronic Health Records Are the Next Frontier for the Genetics of Substance Use Disorders.Trends in genetics : TIG · 2019Article
- Information standards for recording alcohol use in electronic health records: findings from a national consultation.BMC medical informatics and decision making · 2018Article
- Representation of occupational information across resources and validation of the occupational data for health model.Journal of the American Medical Informatics Association : JAMIA · 2018Article
- Using Neural Multi-task Learning to Extract Substance Abuse Information from Clinical Notes.AMIA ... Annual Symposium proceedings. AMIA Symposium · 2018Article
- Representation of Social History Factors Across Age Groups: A Topic Analysis of Free-Text Social Documentation.AMIA ... Annual Symposium proceedings. AMIA Symposium · 2017Article
- Content and Quality of Free-Text Occupation Documentation in the Electronic Health Record.AMIA ... Annual Symposium proceedings. AMIA Symposium · 2016Article
- Investigating Longitudinal Tobacco Use Information from Social History and Clinical Notes in the Electronic Health Record.AMIA ... Annual Symposium proceedings. AMIA Symposium · 2016Article
- Identifying Family History and Substance Use Associations for Adult Epilepsy from the Electronic Health Record.AMIA Joint Summits on Translational Science proceedings. AMIA Joint Summits on Translational Science · 2016Article
- Automated Extraction of Substance Use Information from Clinical Texts.AMIA ... Annual Symposium proceedings. AMIA Symposium · 2015Article
- Examining the use, contents, and quality of free-text tobacco use documentation in the Electronic Health Record.AMIA ... Annual Symposium proceedings. AMIA Symposium · 2014Article
Corrections and comments
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Authors and funding
2 authors.
Funding
Abstract
backgroundAlcohol 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.
objectiveTo characterize the use and contents of free-text documentation for alcohol use in the social history module of an EHR.
methodsThis 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.
resultsThe 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.
conclusionsBASED 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.
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Registered trials
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