title: Examining the use, contents, and quality of free-text tobacco use documentation in the Electronic Health Record.
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.
authors.affiliation: Center for Clinical & Translational Science, University of Vermont, Burlington, VT ; Medicine, University of Vermont, Burlington, VT.
authors.forename: Elizabeth S
authors.initials: ES
authors.lastname: Chen
authors.affiliation: Center for Clinical & Translational Science, University of Vermont, Burlington, VT.
authors.forename: Elizabeth W
authors.initials: EW
authors.lastname: Carter
authors.affiliation: Center for Clinical & Translational Science, University of Vermont, Burlington, VT ; Microbiology & Molecular Genetics, University of Vermont, Burlington, VT.
authors.forename: Indra Neil
authors.initials: IN
authors.lastname: Sarkar
authors.affiliation: Institute for Health Informatics, University of Minnesota, Minneapolis, MN ; Division of Applied Research, Allina Health, Minneapolis, MN.
authors.forename: Tamara J
authors.initials: TJ
authors.lastname: Winden
authors.affiliation: Institute for Health Informatics, University of Minnesota, Minneapolis, MN ; Surgery, University of Minnesota, Minneapolis, MN.
authors.forename: Genevieve B
authors.initials: GB
authors.lastname: Melton
mesh_terms: D059019:Clinical Coding / Q000379:methods*; D004282:Documentation; D057286:Electronic Health Records; D006801:Humans; D009323:Natural Language Processing; D064424:Tobacco Use