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

Abstract

BackgroundClinicians are advised to ask patients about their alcohol use and provide brief interventions and specialist referral, but this is poorly implemented in practice. We undertook a national consultation to develop appropriate standards for recording information about alcohol use in electronic health records in the UK. MethodsA wide range of stakeholders in the UK was consulted about recording alcohol use in electronic health records via a multidisciplinary stakeholder workshop and online survey. Stakeholders were identified by the Royal College of Physicians Health Informatics Unit and the project team. Notes were taken at the workshop and used to inform the survey. The survey asked participants about the appropriateness of the proposed information standards, implementation barriers and facilitators, potential applications for patient care, and patient safety concerns. Responses were thematically analysed using the Consolidated Framework for Implementation Research. Findings31 stakeholders participated in the workshop and 105 in the online survey. Participants included patients, health-care 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 the optimal tools for recording alcohol use in electronic health records but that information should also be captured on relevant interventions. Stakeholders highlighted various factors that could influence implementation, including having clear care pathways and implementation guidance, information sharing between health service providers (potentially through summary care records), resourcing the implementation process, integrating alcohol screening with existing clinical pathways, having accessible clinical information systems (including a simple interface that aids understanding of alcohol units), financial incentives, training of health-care professionals, and strong clinical leadership and engagement. Implementation of the standards would need to ensure patients are not stigmatised and that patient confidentiality is maintained. InterpretationA wide range of stakeholders agreed that AUDIT and AUDIT-C are appropriate standards for recording alcohol use in electronic health records with the addition of 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 electronic health records. FundingFunding for patient involvement was provided by the National Institute for Health Research Patient Involvement Fund.