دورية أكاديمية
Structured and unstructured social risk factor documentation in the electronic health record underestimates patients' self-reported risks.
| العنوان: | Structured and unstructured social risk factor documentation in the electronic health record underestimates patients' self-reported risks. |
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| المؤلفون: | Iott BE; Center for Clinical Informatics and Improvement Research, University of California, San Francisco, San Francisco, CA, United States.; Social Interventions Research and Evaluation Network, University of California, San Francisco, San Francisco, CA, United States., Rivas S; Social Interventions Research and Evaluation Network, University of California, San Francisco, San Francisco, CA, United States., Gottlieb LM; Social Interventions Research and Evaluation Network, University of California, San Francisco, San Francisco, CA, United States.; Center for Health and Community, University of California, San Francisco, San Francisco, CA, United States.; Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA, United States., Adler-Milstein J; Center for Clinical Informatics and Improvement Research, University of California, San Francisco, San Francisco, CA, United States.; Department of Medicine, University of California, San Francisco, San Francisco, CA, United States., Pantell MS; Center for Health and Community, University of California, San Francisco, San Francisco, CA, United States.; Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States. |
| المصدر: | Journal of the American Medical Informatics Association : JAMIA [J Am Med Inform Assoc] 2024 Feb 16; Vol. 31 (3), pp. 714-719. |
| نوع المنشور: | Journal Article |
| اللغة: | English |
| بيانات الدورية: | Publisher: Oxford University Press Country of Publication: England NLM ID: 9430800 Publication Model: Print Cited Medium: Internet ISSN: 1527-974X (Electronic) Linking ISSN: 10675027 NLM ISO Abbreviation: J Am Med Inform Assoc Subsets: MEDLINE |
| أسماء مطبوعة: | Publication: 2015- : Oxford : Oxford University Press Original Publication: Philadelphia, PA : Hanley & Belfus, c1993- |
| مواضيع طبية MeSH: | Electronic Health Records* , Documentation*/methods, Humans ; Self Report ; Prevalence ; Risk Factors |
| مستخلص: | Objectives: National attention has focused on increasing clinicians' responsiveness to the social determinants of health, for example, food security. A key step toward designing responsive interventions includes ensuring that information about patients' social circumstances is captured in the electronic health record (EHR). While prior work has assessed levels of EHR "social risk" documentation, the extent to which documentation represents the true prevalence of social risk is unknown. While no gold standard exists to definitively characterize social risks in clinical populations, here we used the best available proxy: social risks reported by patient survey. Materials and Methods: We compared survey results to respondents' EHR social risk documentation (clinical free-text notes and International Statistical Classification of Diseases and Related Health Problems [ICD-10] codes). Results: Surveys indicated much higher rates of social risk (8.2%-40.9%) than found in structured (0%-2.0%) or unstructured (0%-0.2%) documentation. Discussion: Ideally, new care standards that include incentives to screen for social risk will increase the use of documentation tools and clinical teams' awareness of and interventions related to social adversity, while balancing potential screening and documentation burden on clinicians and patients. Conclusion: EHR documentation of social risk factors currently underestimates their prevalence. (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.) |
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| فهرسة مساهمة: | Keywords: ICD-10 Z codes; clinical free-text notes; documentation; electronic health records; social determinants of health |
| تواريخ الأحداث: | Date Created: 20240112 Date Completed: 20240219 Latest Revision: 20240219 |
| رمز التحديث: | 20240219 |
| مُعرف محوري في PubMed: | PMC10873825 |
| DOI: | 10.1093/jamia/ocad261 |
| PMID: | 38216127 |
| قاعدة البيانات: | MEDLINE |
| تدمد: | 1527-974X |
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| DOI: | 10.1093/jamia/ocad261 |