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Information standards for recording alcohol use in electronic health records: findings from a national consultation

机译：在电子健康记录中记录酒精使用的信息标准：全国咨询的结果

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Alcohol misuse is an important cause of premature disability and death. While clinicians are recommended to ask patients about alcohol use and provide brief interventions and specialist referral, this is poorly implemented in routine practice. We undertook a national consultation to ascertain the appropriateness of proposed standards for recording information about alcohol use in electronic health records (EHRs) in the UK and to identify potential barriers and facilitators to their implementation in practice. A wide range of stakeholders in the UK were consulted about the appropriateness of proposed information standards for recording alcohol use in EHRs via a multi-disciplinary stakeholder workshop and online survey. Responses to the survey were thematically analysed using the Consolidated Framework for Implementation Research. Thirty-one stakeholders participated in the workshop and 100 in the online survey. This included patients and carers, healthcare professionals, researchers, public health specialists, informaticians, and clinical information system suppliers. There was broad consensus that the Alcohol Use Disorders Identification Test (AUDIT) and AUDIT-Consumption (AUDIT-C) questionnaires were appropriate standards for recording alcohol use in EHRs but that the standards should also address interventions for alcohol misuse. Stakeholders reported a number of factors that might influence implementation of the standards, including having clear care pathways and an implementation guide, sharing information about alcohol use between health service providers, adequately resourcing the implementation process, integrating alcohol screening with existing clinical pathways, having good clinical information systems and IT infrastructure, providing financial incentives, having sufficient training for healthcare workers, and clinical leadership and engagement. Implementation of the standards would need to ensure patients are not stigmatised and that patient confidentiality is robustly maintained. A wide range of stakeholders agreed that use of AUDIT-C and AUDIT are appropriate standards for recording alcohol use in EHRs in addition to recording interventions for alcohol misuse. The findings of this consultation will be used to develop an appropriate information model and implementation guide. Further research is needed to pilot the standards in primary and secondary care.
机译：滥用酒精是导致过早残疾和死亡的重要原因。虽然建议临床医生向患者询问饮酒情况，并提供简短的干预措施和专科医生转诊，但在常规实践中实施情况不佳。我们进行了一次全国咨询，以确定在英国电子健康记录（EHR）中记录有关酒精使用的信息的拟议标准是否适当，并确定在实践中实施酒精的潜在障碍和促进因素。通过多学科的利益相关者研讨会和在线调查，就英国建议的信息标准是否适用于记录电子病历中的酒精使用情况向英国的众多利益相关者进行了咨询。使用“实施研究综合框架”对调查的答复进行了主题分析。 31名利益相关者参加了研讨会，100名利益相关者参加了在线调查。其中包括患者和护理人员，医疗保健专业人员，研究人员，公共卫生专家，信息学家和临床信息系统供应商。大家普遍认为，酒精使用障碍识别测试（AUDIT）和消费量审计（AUDIT-C）问卷是记录EHR中酒精使用的适当标准，但该标准还应解决酒精滥用的干预措施。利益相关者报告了许多可能影响标准实施的因素，包括拥有清晰的护理途径和实施指南，在医疗服务提供者之间共享有关酒精使用的信息，充分地落实实施过程，将酒精筛查与现有临床途径相结合，具有良好的临床信息系统和IT基础架构，提供经济激励，对医护人员进行充分的培训，以及临床领导和参与。标准的实施将需要确保患者没有受到污名化，并且患者的机密性得到了强有力的维护。众多利益相关者同意，除了记录酒精滥用干预措施外，使用AUDIT-C和AUDIT是记录EHR中酒精使用的适当标准。这次咨询的结果将用于制定适当的信息模型和实施指南。需要进一步研究以试行初级和二级保健标准。

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