Do you vape? Leveraging electronic health records to assess clinician documentation of electronic nicotine delivery system use among adolescents and adults

Abstract

Use of electronic nicotine delivery systems (ENDS) has increased substantially over the past decade. However, unlike smoking, which is systematically captured by clinicians through routine screening and discrete documentation fields in the electronic health record (EHR), unknown is the extent to which clinicians are documenting patients’ use of ENDS. Data were gathered from medical visits with patients aged 12 and older (N = 9,119; 55% male) treated in a large, integrated healthcare system. We used natural language processing to assess the incidence rates of clinician documentation of patients’ ENDS use in unstructured tobacco comments in the EHR, and the words most frequently documented in relation to ENDS, from 2006–2015. ENDS documentation in the EHR increased dramatically over time (from 0.01 to 9.5 per 10,000 patients, p < 0.0001), particularly among adults aged 18–24 and 25–44. Most prevalent were “e-cig,” “electronic cigarettes”, and “vape,” with much variation in spelling and phrasing of these words. Records of adolescent and young adult patients were more likely to contain the word “vape”, and less likely to have “e-cig” and “electronic cigarette” than records of adults (ps < 0.0001). The relatively low observed number of patients with ENDS terms in the EHR suggested vast under documentation. While healthcare providers are increasingly documenting patients’ use of ENDS in the EHR, overall documentation rates remain low. Discrete EHR fields for standard screening and documentation of ENDS that reflect the language used by patients would provide more complete longitudinal population-level surveillance of ENDS use and its association with short- and long-term health outcomes.

Documentation of e-cigarette use and associations with smoking from 2012 to 2015 in an integrated healthcare delivery system

“…Incidence rates of patients' ENDS use based on clinician documentation in the EHR have increased dramatically in recent years, likely reflecting both surges in patient uptake of ENDS and greater patient-provider discussions about ENDS (Young-Wolff et al, 2017;Brown-Johnson et al, 2016). As expected, current smokers-and former smokers, to a lesser extent-had higher incidence rates of ENDS-use documentation each year than never-smokers.…”

“…The peak among current and former smokers in 2014 may be explained by the simultaneous implementation of the Affordable Care Act and the influx of high-priority populations for tobacco control (e.g., men, adults aged 19-34, low-income enrollees) into the healthcare system in 2014 via the California insurance exchange and Medicaid expansion (McAfee et al, 2015; Reichard, 2014; Satre et al, 2016; Covered California, 2014). While our text-based assessment of ENDS-use documentation is novel and represents how the incidence of ENDS documentation has increased over time, results substantially understimate the true incidence of ENDS use (Young-Wolff et al, 2017). Standard ENDS documentation practices and discrete EHR fields for mandatory ENDS documentation that would allow for an enhanced estimate of ENDS incidence and prevalence are recommended.…”

“…As patients increasingly turn to their healthcare providers for information about ENDS (Nickels et al, 2017;Steinberg et al, 2015;El-Shahawy et al, 2016;Kandra et al, 2014), research is critically needed to increase the surveillance of their use in healthcare settings (Young-Wolff et al, 2017). To fill this gap in the literature, we analyzed data from a large, integrated healthcare delivery system to describe the incidence of patients' ENDS use based on clinician documentation in the EHR from 2012 to 2015 and to test whether ENDS use was associated with changes in patients' smoking status (i.e., starting, quitting, relapsing) in the subsequent year using a matched retrospective cohort design.…”

Improved Documentation of Electronic Cigarette Use in an Electronic Health Record

“…This overall rate of use is consistent with the rates observed in those patients with information entered in the new section, with 2.6% of patients reporting every day or some day use, and 2.5% reporting former use. Prior reports suggest that e-cigarette use information appears to be under-reported in the EHR [11,12,14]. Studies examining e-cigarette use information in the EHR suggest several deficiencies, including misclassification and inconsistent documentation practices [10,11,14], with the general lack of structured fields in EHRs to document e-cigarette use serving as one potential barrier [21].…”

“…These documentation efforts are not consistent across clinical practices, nor systematically tracked by the health system. Reliable population health data could bolster research efforts to generate evidence addressing gaps in our understanding of trends in e-cigarette use by patients and their overall impact on health [10,13,14]. These data are also important for clinicians to deliver optimal care, as many may not even be aware of their patients' e-cigarette use [15].…”