An Analysis of Free-Text Alcohol Use Documentation in the Electronic Health Record

Background: Alcohol use is a significant part of a patient's history, but details about consumption are not always documented. Electronic Health Record (EHR) systems have the potential to improve assessment of alcohol use and misuse; however, a challenge is that critical information may be primarily in free-text rather than in a structured and standardized format, thereby limiting its use. Objective: To characterize the use and contents of free-text documentation for alcohol use in the social history module of an EHR. Methods: This study involved a retrospective analysis of 500 alcohol use entries that include structured fields as well as a free-text comment field. Two coding schemes were developed and used to analyze these entries for: (1) quantifying the reasons for using free-text comments and (2) categorizing information in the free-text into separate elements. In addition, for entries indicating possible alcohol misuse, a preliminary review of other structured parts of the EHR was conducted to determine if this was also documented elsewhere. Results: The top three reasons for using free-text were limited ability to describe alcohol use frequency (75%), amount (22%), and status (18%) with available structured fields. Within the free-text, descriptions of frequency were most common (79%) using words or phrases conveying occasional (61%), daily (13%), or weekly (12%) use. Of the 36 cases suggesting alcohol misuse, 44% had mention of alcohol problems in the problem list or past medical history. Conclusions: Based on the early findings, implications for improving the structured collection and use of alcohol use information in the EHR are provided in four areas: (1) system enhancements, (2) user training, (3) decision support, and (4) standards. Next steps include examining how alcohol use is documented in other parts of the EHR (e. g., clinical notes) and how documentation practices vary based on patient, provider, and clinic characteristics.