An analysis of free-text alcohol use documentation in the electronic health record

Applied Clinical Informatics

Volumn 5, Issue 2, 2014, Pages 402-415

  Chen, E S ^a,b   Garcia Webb, M ^c  

^a UNIVERSITY OF VERMONT COLLEGE OF MEDICINE   (United States)

^b University of Vermont   (United States)

^c UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL   (United States)

Author keywords

Alcohol drinking; Alcoholism; Electronic health records; Medical history taking

Indexed keywords

DOCUMENTATION; DRINKING BEHAVIOR; ELECTRONIC MEDICAL RECORD; HUMAN; PATIENT CARE; PROCEDURES; STANDARD; STANDARDS;

ALCOHOL DRINKING; DOCUMENTATION; ELECTRONIC HEALTH RECORDS; HUMANS; PATIENT CARE; REFERENCE STANDARDS;

EID: 84904103477     PISSN: None     EISSN: 18690327     Source Type: Journal    
DOI: 10.4338/ACI-2013-12-RA-0101     Document Type: Article

References (45)

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(5): 516-524.
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(7): 830-842.
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(6): 648-66.
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(3): 299-306.
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(5): 294-298.
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.
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(3): 210-218.
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.
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(1): 44-50.
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.
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.
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(7): 783-788.
13. Friedmann PD. Clinical practice. Alcohol use in adults. The New England journal of medicine 2013; 368(4): 365-373.
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.
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.
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. 1): 11-17.
17. Seppa K, Lahtinen T, Antila S, Aalto M. Alcohol drinking among emergency patients-alcometer use and documentation. Alcohol and alcoholism 2004; 39(3): 262-265.
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.
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(3): 403-409.
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.
21. Freedy JR, Ryan K. Alcohol use screening and case finding: screening tools, clinical clues, and making the diagnosis. Primary care 2011; 38(1): 91-103.
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(1): 72-79.
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(2): 179-187.
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(4): 97-112.
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(6): 1019-1024.
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.
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(8): 890-895.
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.
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(1): 14-24.
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.
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(6): 883-889.
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.
33. Fletcher Allen Health Care. [January 2014]; Available from: http://www.fletcherallen.org/.
34. McDowell SW, Wahl R, Michelson J. Herding cats: the challenges of EMR vendor selection. Journal of healthcare information management 2003; 17(3): 63-71.
35. Epic Systems Corporation. [January 2014]; Available from: http://www.epic.com/.
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.
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.
38. Health Level Seven International (HL7). [December 2013]; Available from: http://www.hl7.org/.
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(1): 30-39.
40. openEHR. [December 2013]; Available from: http://www.openehr.org/.
41. openEHR Clinical Knowledge Manager. [December 2013]; Available from: http://www.openehr.org/ckm/.
42. SNOMED Clinical Terms (SNOMED CT). [December 2013]; Available from: http://www.ihtsdo.org/ snomed-ct/.
43. Behavioral Risk Factor Surveillance System. [December 2013]; Available from: http://www.cdc.gov/brfss/.
44. National Health and Nutrition Examination Survey. [December 2013]; Available from: http://www.cdc. gov/nchs/nhanes.htm.
45. National Health Interview Survey. [December 2013]; Available from: http://www.cdc.gov/nchs/nhis.htm.