TY - JOUR
T1 - Regional Variations in Documentation of Sexual Trauma Concepts in Electronic Medical Records in the United States Veterans Health Administration
AU - Jones, Audrey L.
AU - Pettey, Warren B.P.
AU - Carter, Marjorie E.
AU - Brignone, Emily
AU - Redd, Andrew
AU - Suo, Ying
AU - Divita, Guy
AU - Blais, Rebecca K.
AU - Fargo, Jamison D.
AU - Gundlapalli, Adi V.
N1 - Publisher Copyright:
©2019 AMIA - All rights reserved.
PY - 2019
Y1 - 2019
N2 - Background: Experiences of sexual trauma are associated with adverse patient and health system outcomes, but are not systematically documented in electronic health records (EHR). Objective: To describe variations in how sexual trauma is documented in the Veterans Health Adminstration's EHR. Methods: Sexual trauma concepts were extracted from from 362,559 clinical notes using a natural language processing pipeline. Results: We observed variations in the presence of sexual trauma in notes across five United States regions: Pacific, Continental, Midwest, North Atlantic, Southeast. We also observed variations in the types of notes used to document sexual trauma (e.g., mental health, primary care) and sources of sexual trauma (e.g., adult, childhood, military) mentioned in the EHR. Our findings illustrate potential differences in cultural norms related to patient disclosure of sensitive information, and provider documentation. Standardized protocol for eliciting and documenting sexual trauma histories are needed to ensure Veteran access to high quality, trauma-informed care.
AB - Background: Experiences of sexual trauma are associated with adverse patient and health system outcomes, but are not systematically documented in electronic health records (EHR). Objective: To describe variations in how sexual trauma is documented in the Veterans Health Adminstration's EHR. Methods: Sexual trauma concepts were extracted from from 362,559 clinical notes using a natural language processing pipeline. Results: We observed variations in the presence of sexual trauma in notes across five United States regions: Pacific, Continental, Midwest, North Atlantic, Southeast. We also observed variations in the types of notes used to document sexual trauma (e.g., mental health, primary care) and sources of sexual trauma (e.g., adult, childhood, military) mentioned in the EHR. Our findings illustrate potential differences in cultural norms related to patient disclosure of sensitive information, and provider documentation. Standardized protocol for eliciting and documenting sexual trauma histories are needed to ensure Veteran access to high quality, trauma-informed care.
UR - http://www.scopus.com/inward/record.url?scp=85083755452&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85083755452&partnerID=8YFLogxK
M3 - Article
C2 - 32308845
AN - SCOPUS:85083755452
SN - 1559-4076
VL - 2019
SP - 514
EP - 522
JO - AMIA ... Annual Symposium proceedings. AMIA Symposium
JF - AMIA ... Annual Symposium proceedings. AMIA Symposium
ER -