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首页> 外文期刊>Journal of studies on alcohol and drugs. >Assessing Brief Intervention for Unhealthy Alcohol Use: A Comparison of Electronic Health Record Documentation and Patient Self-Report
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Assessing Brief Intervention for Unhealthy Alcohol Use: A Comparison of Electronic Health Record Documentation and Patient Self-Report

机译：评估不健康饮酒的简要干预：电子健康记录文件和患者自我报告的比较

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Objective: Alcohol screening and brief intervention (BI) are recommended preventive health practices. Veterans Health Administration (VA) uses a performance measure to incentivize BI delivery. Concerns have been raised about the validity of the BI performance measure, which relies on electronic health record (EHR) documentation. Our objective was to assess concordance between EHR-based documentation and patient-reported receipt of BI, and to examine correlates of concordance. Method: Patients with a documented positive screen for unhealthy alcohol use at VA Greater Los Angeles primary care clinics were surveyed (within 15 days on average) in 2013-2014. Documented BI was indicated by an EHR note that the patient was advised to drink within recommended limits or reduce or abstain from drinking. Patient-reported receipt of BI corresponded to an affirmative response to questions on whether a VA provider advised the patient to drink less or abstain. Patient report and documentation were assessed over the same period. Results: Documented and patient-reported receipt of BI had low concordance. Almost all patients who reported receiving BI had documentation of BI (93%; 95% CI [90%, 95%]), but only 63% [59%, 67%] of patients with documented BI reported receiving it. BI concordance was associated with more severe unhealthy alcohol use and drinking-related consequences, mental health comorbidity, and greater readiness-to-change alcohol use. Conclusions: Discrepancies between EHR documentation and patient-reported BI raise concerns about performance measure validity. Patient-reported receipt of BI could be an alternative or complementary measure of BI.
机译：目的：建议采用酒精筛选和简要干预（BI）预防性健康实践。退伍军人健康管理局（VA）使用绩效措施来激励双交付。关于双重绩效措施的有效性提出了担忧，依赖于电子健康记录（EHR）文件。我们的目标是评估基于EHR的文件和患者报告的BI之间的一致性，并审查一致性的相关性。方法：2013 - 2014年，在VA更大的洛杉矶初级保健诊所进行了不健康饮酒的患者的患者，2013-2014岁记录的BI由EHR表示，建议患者在建议的限度或减少或戒酒中饮用。患者报告的BI的收到对应于关于VA提供者是否建议患者饮酒少或弃权的问题的肯定响应。患者报告和文件在同一时期进行评估。结果：记录和患者报告的BI具有低调。几乎所有报告BI的患者都有BI的文件（93％; 95％CI [90％，95％]），但仅63％[59％，67％]患者记录的BI报告接受它。双协调与更严重的不健康的酒精使用和饮用相关的后果，心理健康合并症以及更加准备的准备，更改饮酒。结论：EHR文件与患者报告的BI之间的差异提高了对性能措施有效性的担忧。患者报告的BI的收据可以是BI的替代或补充衡量标准。

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