Documenting Alcohol Use as a Risk Factor in Primary Care Practices in Alberta

  • Author(s) / Creator(s)
  • Introduction:. Clinical guidelines for problem drinking and initiatives to improve patient data suggest that primary care physicians should be screening for and documenting alcohol use on a regular basis. The objectives of this research were to (1) Determine the proportion of patients with alcohol use documented in Electronic Medical Records (EMRs); (2) Determine the number of ways physicians document alcohol use and describe the patterns of alcohol documentation. Methods: Data were abstracted from the Wolf and Med Access EMR systems of 71 participating sentinel physicians in Alberta, Canada from March 1, 2003 to March 31, 2012. The EMR data were examined to determine the proportion of adults in the yearly contact group with alcohol use documented in the EMR risk factor fields. Analysis and Results: A content analysis was performed to code and analyze the various terms physicians used to document alcohol use in the EMR. A total of 62,727 patients’ EMR records were examined; of these only 12,548 (20%) had alcohol documented somewhere in their EMR data. Of all the alcohol documentation 75% occurred in the risk factor fields. Physicians used 1,178 unique text strings to characterize alcohol use. Alcohol documentation was categorized into six themes: alcohol screening tools; non-drinker status; ex-drinker status; alcohol use disorder status; quantification of alcohol use; qualitative description of alcohol use. Conclusions and Implications: EMR documentation of alcohol use is variable and inconsistent. It is difficult to understand individual patient alcohol risks, prognosis, and potential for comorbidity without standard entry and terminology. Improvements can be made to the systematic documentation of patient alcohol use by using standardized terms including standard data entry fields to describe alcohol risk factor information in order to produce more clinically meaningful data. Such improvements may produce more clinically meaningful data for practice management and prevention strategies.

  • Date created
  • Subjects / Keywords
  • Type of Item
    Conference/Workshop Poster
  • DOI
  • License
    Attribution-NonCommercial-NoDerivatives 3.0 International