Title: Using discrete field documentation in Epic EMR for clinical research of hepatitis B

Background: Many centres are using electronic medical records (EMR) for clinical documentation. Our centre adopted Epic EMR in June 2022.

Purpose: Explore the feasibility of clinical documentation using discrete field documentation in Epic EMR to facilitate practice audit and clinical research.

Method: Discrete field documentation was used preferentially over free text documentation where possible: Surgical History: Liver biopsy, Endoscopy, HCC treatment; Medications; Social History: Race, Marital Status, Substance Use (Tobacco, Alcohol), Family History. Medical History leveraged redundancy in ICD-10 to categorize Hepatitis B status as Acute (B16.9), Undifferentiated chronic (B18.9), HBV without HDV (B18.1), HBV+HDV (B17.0), HBV without HDV, Immune Tolerant (B18.10). R76.8 was used as a marker of HBeAg positive status. Severity states such as cirrhosis, HCC, varices also documented in this manner. Data summarized using the SlicerDicer module of Epic.

Result(s): From June 6, 2022 to Jun 30, 2023, N=2,614 individual patients have been assessed. N=1,148 had HBV infection (2 acute). An additional 87 had functional cure of chronic HBV infection.

Conclusion(s): Discrete field clinical documentation can be used in a busy clinic to facilitate live clinical audits and facilitate research individually and potentially wider collaboration in the many sites that also use Epic EMR.