Department of Family Medicine, G012 Health Sciences Centre, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada.
Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
BMC Res Notes. 2023 Feb 1;16(1):9. doi: 10.1186/s13104-023-06274-6.
Documenting cannabis use is important for patient care, but no formal requirements for consistent reporting exist in primary care. The objective of this study was to understand how cannabis use is documented in primary care electronic medical record (EMR) data.
This was a cross-sectional study using de-identified EMR data from over 398,000 patients and 333 primary care providers in Alberta, Canada. An automated pattern-matching algorithm was developed to identify text and ICD-9 diagnostic codes indicating cannabis use in the EMR. There was a total of 11,724 records indicating cannabis use from 4652 patients, representing approximately 1.2% of the patient sample. Commonly used terms and ICD-9 codes included cannabis, marijuana/marihuana, THC, 304.3 and 305.2. Nabilone was the most frequently prescribed cannabinoid medication. Slightly more males and those with a chronic condition had cannabis use recorded more often. Overall, very few patients have cannabis use recorded in primary care EMR data and this is not captured in a systematic way. We propose several strategies to improve the documentation of cannabis use to facilitate more effective clinical care, research, and surveillance.
记录大麻使用情况对患者护理很重要，但在初级保健中，没有关于一致性报告的正式要求。本研究的目的是了解大麻使用情况在初级保健电子病历（EMR）数据中是如何记录的。
这是一项使用来自加拿大阿尔伯塔省超过 398000 名患者和 333 名初级保健提供者的去识别 EMR 数据的横断面研究。开发了一种自动模式匹配算法来识别 EMR 中表示大麻使用的文本和 ICD-9 诊断代码。共有 11724 份记录表明 4652 名患者有大麻使用情况，占患者样本的约 1.2%。常用术语和 ICD-9 代码包括大麻、大麻/大麻、THC、304.3 和 305.2。纳比隆是最常开的大麻素药物。男性和患有慢性疾病的患者记录大麻使用情况的频率略高。总体而言，很少有患者在初级保健 EMR 数据中记录大麻使用情况，而且这种情况没有以系统的方式记录下来。我们提出了几种改进大麻使用记录的策略，以促进更有效的临床护理、研究和监测。
