Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
Health Informatics Unit, Royal College of Physicians, 11 St Andrews Place, Regent's Park, London, NW1 4LE, UK.
BMC Med Inform Decis Mak. 2018 Jun 7;18(1):36. doi: 10.1186/s12911-018-0612-z.
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.
酒精滥用是导致过早残疾和死亡的一个重要原因。虽然临床医生被建议询问患者的饮酒情况，并提供简短的干预措施和专家转诊，但这在常规实践中执行得很差。我们进行了一次全国性的咨询，以确定在英国电子健康记录（EHR）中记录酒精使用信息的拟议标准是否合适，并确定在实践中实施这些标准的潜在障碍和促进因素。
通过多学科利益相关者研讨会和在线调查，向英国的广泛利益相关者征求了对记录 EHR 中酒精使用情况的拟议信息标准的适宜性意见。使用综合实施研究框架对调查的回应进行了主题分析。
31 名利益相关者参加了研讨会，100 名参加了在线调查。这包括患者和照顾者、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。广泛共识认为，酒精使用障碍识别测试（AUDIT）和 AUDIT-Consumption（AUDIT-C）问卷是记录 EHR 中酒精使用情况的适当标准，但标准也应解决酒精滥用的干预措施。利益相关者报告了一些可能影响标准实施的因素，包括制定明确的护理途径和实施指南、在卫生服务提供者之间共享关于酒精使用的信息、为实施过程提供充足的资源、将酒精筛查与现有临床途径相结合、拥有良好的临床信息系统和 IT 基础设施、提供经济激励、为医疗保健工作者提供足够的培训、以及临床领导力和参与。标准的实施需要确保患者不被污名化，并且患者的保密性得到强有力的维护。
广泛的利益相关者一致认为，除了记录酒精滥用的干预措施外，使用 AUDIT-C 和 AUDIT 是记录 EHR 中酒精使用情况的适当标准。这次咨询的结果将用于开发适当的信息模型和实施指南。还需要进一步研究在初级和二级保健中试点这些标准。
