<mods:mods xmlns:mods="http://www.loc.gov/mods/v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" ID="bdr697495" xsi:schemaLocation="http://www.loc.gov/mods/v3 http://www.loc.gov/mods/v3/mods-3-6.xsd">

    <mods:titleInfo>
        <mods:title>Examining the use, contents, and quality of free-text tobacco use documentation in the electronic health record</mods:title>
    </mods:titleInfo>
    <mods:name type="personal">
        <mods:namePart>Chen, Elizabeth S.</mods:namePart>
        <mods:role>
            <mods:roleTerm type="text" authority="marcrelator">author</mods:roleTerm>
        </mods:role>
    </mods:name>
    <mods:name type="personal">
        <mods:namePart>Carter, Elizabeth W.</mods:namePart>
        <mods:role>
            <mods:roleTerm type="text" authority="marcrelator">author</mods:roleTerm>
        </mods:role>
    </mods:name>
    <mods:name type="personal">
        <mods:namePart>Sarkar, Indra Neil</mods:namePart>
        <mods:role>
            <mods:roleTerm type="text" authority="marcrelator">author</mods:roleTerm>
        </mods:role>
    </mods:name>
    <mods:name type="personal">
        <mods:namePart>Winden, Tamara J.</mods:namePart>
        <mods:role>
            <mods:roleTerm type="text" authority="marcrelator">author</mods:roleTerm>
        </mods:role>
    </mods:name>
    <mods:name type="personal">
        <mods:namePart>Melton, Genevieve B.</mods:namePart>
        <mods:role>
            <mods:roleTerm type="text" authority="marcrelator">author</mods:roleTerm>
        </mods:role>
    </mods:name>



    <mods:typeOfResource>text</mods:typeOfResource>
    <mods:genre authority="aat">papers (documents)</mods:genre>
    <mods:originInfo>
        <mods:dateCreated keyDate="yes" encoding="w3cdtf">2014</mods:dateCreated>
    </mods:originInfo>
    <mods:language>
        <mods:languageTerm type="code" authority="iso639-2b">eng</mods:languageTerm>
    </mods:language>
    <mods:note displayLabel="Source">Electronic Health Record</mods:note>
    <mods:note displayLabel="Method">Model</mods:note>
    <mods:note displayLabel="Method">Data Quality</mods:note>
    <mods: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.</mods:abstract>
    <mods:note type="funding">This research was supported in part by the National Library of Medicine of the National Institutes of Health under award number R01LM011364</mods:note>
    <mods:note>Paper presented at the 2014 AMIA Annual Symposium</mods:note>

    <mods:subject authority="local">
        <mods:topic>Tobacco use</mods:topic>
    </mods:subject>


    <mods:relatedItem type="host" displayLabel="Published in">
        <mods:titleInfo>
            <mods:title>AMIA Annual Symposium Proceedings</mods:title>

        </mods:titleInfo>
        <mods:originInfo>
            <mods:dateCreated>2014 Nov 14</mods:dateCreated>
            <mods:dateCreated keyDate="yes" encoding="w3cdtf">2014-11-14</mods:dateCreated>
        </mods:originInfo>
        <mods:physicalDescription>
            <mods:extent>p. 366-374</mods:extent>
        </mods:physicalDescription>
        <mods:identifier type="PubMed ID">PMID: 25954340</mods:identifier>
        <mods:identifier type="PubMed Central PMCID">PMC4419995</mods:identifier>


    </mods:relatedItem>
    <mods:accessCondition xmlns:xlink="http://www.w3.org/1999/xlink" type="use and reproduction" xlink:href="https://creativecommons.org/licenses/by-nc/4.0/">This work is licensed under a
        Creative Commons Attribution-NonCommercial 4.0 International License</mods:accessCondition>
    <mods:accessCondition xmlns:xlink="http://www.w3.org/1999/xlink" type="logo" xlink:href="https://i.creativecommons.org/l/by-nc/4.0/88x31.png"/>
</mods:mods>