title: Leveraging Electronic Health Care Record Information to Measure Pressure Ulcer Risk in Veterans With Spinal Cord Injury: A Longitudinal Study Protocol.
abstract: BACKGROUND
  Pressure ulcers (PrUs) are a frequent, serious, and costly complication for veterans with spinal cord injury (SCI). The health care team should periodically identify PrU risk, although there is no tool in the literature that has been found to be reliable, valid, and sensitive enough to assess risk in this vulnerable population.
  
  
  OBJECTIVE
  The immediate goal is to develop a risk assessment model that validly estimates the probability of developing a PrU. The long-term goal is to assist veterans with SCI and their providers in preventing PrUs through an automated system of risk assessment integrated into the veteran's electronic health record (EHR).
  
  
  METHODS
  This 5-year longitudinal, retrospective, cohort study targets 12,344 veterans with SCI who were cared for in the Veterans Health Administration (VHA) in fiscal year (FY) 2009 and had no record of a PrU in the prior 12 months. Potential risk factors identified in the literature were reviewed by an expert panel that prioritized factors and determined if these were found in structured data or unstructured form in narrative clinical notes for FY 2009-2013. These data are from the VHA enterprise Corporate Data Warehouse that is derived from the EHR structured (ie, coded in database/table) or narrative (ie, text in clinical notes) data for FY 2009-2013.
  
  
  RESULTS
  This study is ongoing and final results are expected in 2017. Thus far, the expert panel reviewed the initial list of risk factors extracted from the literature; the panel recommended additions and omissions and provided insights about the format in which the documentation of the risk factors might exist in the EHR. This list was then iteratively refined through review and discussed with individual experts in the field. The cohort for the study was then identified, and all structured, unstructured, and semistructured data were extracted. Annotation schemas were developed, samples of documents were extracted, and annotations are ongoing. Operational definitions of structured data elements have been created and steps to create an analytic dataset are underway.
  
  
  CONCLUSIONS
  To our knowledge, this is the largest cohort employed to identify PrU risk factors in the United States. It also represents the first time natural language processing and statistical text mining will be used to expand the number of variables available for analysis. A major strength of this quantitative study is that all VHA SCI centers were included in the analysis, reducing potential for selection bias and providing increased power for complex statistical analyses. This longitudinal study will eventually result in a risk prediction tool to assess PrU risk that is reliable and valid, and that is sensitive to this vulnerable population.
authors.affiliation: Center of Innovation on Disability and Rehabilitation Research, Health Services Research and Development, Department of Veterans Affairs, Tampa, FL, United States.|College of Public Health, University of South Florida, Tampa, FL, United States.
authors.forename: Stephen L
authors.identifier: http://orcid.org/0000-0001-7524-7380
authors.initials: SL
authors.lastname: Luther
authors.affiliation: Center of Innovation on Disability and Rehabilitation Research, Health Services Research and Development, Department of Veterans Affairs, Tampa, FL, United States.|Tampa VA Research and Education Foundation, Inc, Tampa, FL, United States.
authors.forename: Susan S
authors.identifier: http://orcid.org/0000-0002-3600-2206
authors.initials: SS
authors.lastname: Thomason
authors.affiliation: VA Boston Healthcare System, VA New England Healthcare System, Department of Veterans Affairs, West Roxbury, MA, United States.
authors.forename: Sunil
authors.identifier: http://orcid.org/0000-0002-3736-5121
authors.initials: S
authors.lastname: Sabharwal
authors.affiliation: Center of Innovation on Disability and Rehabilitation Research, Health Services Research and Development, Department of Veterans Affairs, Tampa, FL, United States.
authors.forename: Dezon K
authors.identifier: http://orcid.org/0000-0002-8241-5319
authors.initials: DK
authors.lastname: Finch
authors.affiliation: Center of Innovation on Disability and Rehabilitation Research, Health Services Research and Development, Department of Veterans Affairs, Tampa, FL, United States.|Muma College of Business, University of South Florida, Tampa, FL, United States.
authors.forename: James
authors.identifier: http://orcid.org/0000-0001-5780-733X
authors.initials: J
authors.lastname: McCart
authors.affiliation: Center of Innovation on Disability and Rehabilitation Research, Health Services Research and Development, Department of Veterans Affairs, Tampa, FL, United States.
authors.forename: Peter
authors.identifier: http://orcid.org/0000-0003-3387-3943
authors.initials: P
authors.lastname: Toyinbo
authors.affiliation: Center of Innovation on Disability and Rehabilitation Research, Health Services Research and Development, Department of Veterans Affairs, Tampa, FL, United States.
authors.forename: Lina
authors.identifier: http://orcid.org/0000-0001-9999-4989
authors.initials: L
authors.lastname: Bouayad
authors.affiliation: Geriatrics Research Education and Clinical Care, Tennessee Valley Healthcare System, Department of Veterans Affairs, Nashville, TN, United States.|Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States.|Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States.|Division of General Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, United States.
authors.forename: Michael E
authors.identifier: http://orcid.org/0000-0003-3217-4147
authors.initials: ME
authors.lastname: Matheny
authors.affiliation: Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States.|Research and Development Service, Tennessee Valley Healthcare System, Department of Veterans Affairs, Nashville, TN, United States.
authors.forename: Glenn T
authors.identifier: http://orcid.org/0000-0002-5368-7737
authors.initials: GT
authors.lastname: Gobbel
authors.affiliation: Center of Innovation on Disability and Rehabilitation Research, Health Services Research and Development, Department of Veterans Affairs, Tampa, FL, United States.|College of Public Health, University of South Florida, Tampa, FL, United States.|College of Nursing, University of South Florida, Tampa, FL, United States.
authors.forename: Gail
authors.identifier: http://orcid.org/0000-0002-4608-0128
authors.initials: G
authors.lastname: Powell-Cope
keywords: natural language processing; pressure ulcer; risk assessment; spinal cord injury; text mining