This project's aim is to develop information standards for the recording of patients’ alcohol and tobacco use in electronic health records and thus aid the identification of at-risk patients who require support.
Clinicians, public health specialists and researchers at the University of Birmingham and Queen Elizabeth Hospital Birmingham, in partnership with the RCP Health Informatics Unit, have developed draft information standards for recording alcohol and tobacco use in electronic health records.
The objectives of these standards are to record information on alcohol and tobacco use for adults and adolescents that:
The draft standards are currently being reviewed by the assurance committee of the Professional Record Standards Body for health and social care and will then be circulated to relevant patient and professional bodies to seek their support and endorsement.
Implementation of the standards could improve the quality of recording information about alcohol and tobacco use in electronic health records and thus aid the identification of at-risk patients who require support. This could improve the delivery of preventative care, such as the delivery of brief advice and referral to support services. Implementation of the standards could also provide important clinical information that may be relevant for diagnostic assessment.
The data generated from implementation of the standards could also be used for clinical audit and for health needs assessments, and could be used by health service managers and commissioners to improve the quality of preventative and clinical care for patients.
The following journal articles have been published in relation to this project: