Title Information
Title
Examining the use, contents, and quality of free-text tobacco use documentation in the electronic health record
Name: Personal
Name Part
Chen, Elizabeth S.
Role
Role Term: Text (marcrelator)
author
Name: Personal
Name Part
Carter, Elizabeth W.
Role
Role Term: Text (marcrelator)
author
Name: Personal
Name Part
Sarkar, Indra Neil
Role
Role Term: Text (marcrelator)
author
Name: Personal
Name Part
Winden, Tamara J.
Role
Role Term: Text (marcrelator)
author
Name: Personal
Name Part
Melton, Genevieve B.
Role
Role Term: Text (marcrelator)
author
Type of Resource
text
Genre (aat)
papers (documents)
Origin Information
Date Created (keyDate="yes", encoding="w3cdtf")
2014
Language
Language Term: Code (ISO639-2B)
eng
Note (displayLabel="Source")
Electronic Health Record
Note (displayLabel="Method")
Model
Note (displayLabel="Method")
Data Quality
Abstract
Recent initiatives have emphasized the potential role of Electronic Health Record (EHR) systems for improving tobacco use assessment and cessation. In support of these efforts, the goal of the present study was to examine tobacco use documentation in the EHR with an emphasis on free-text. Three coding schemes were developed and applied to analyze 525 tobacco use entries, including structured fields and a free-text comment field, from the social history module of an EHR system to characterize: (1) potential reasons for using free-text, (2) contents within the free-text, and (3) data quality issues. Free-text was most commonly used due to limitations for describing tobacco use amount (23.2%), frequency (26.9%), and start or quit dates (28.2%) as well as secondhand smoke exposure (17.9%) using a variety of words and phrases. The collective results provide insights for informing system enhancements, user training, natural language processing, and standards for tobacco use documentation.
Note: funding
This research was supported in part by the National Library of Medicine of the National Institutes of Health under award number R01LM011364
Note
Paper presented at the 2014 AMIA Annual Symposium
Subject (Local)
Topic
Tobacco use
Related Item: Host (displayLabel="Published in")
Title Information
Title
AMIA Annual Symposium Proceedings
Origin Information
Date Created
2014 Nov 14
Date Created (keyDate="yes", encoding="w3cdtf")
2014-11-14
Physical Description
Extent
p. 366-374
Identifier: PubMed ID
PMID: 25954340
Identifier: PubMed Central PMCID
PMC4419995
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