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Table 2 Electronic health record data captured in patients enrolled in GaPO

From: Genetics and prescription opioid use (GaPO): study design for consenting a cohort from an existing biobank to identify clinical and genetic factors influencing prescription opioid use and abuse

Data variable Variable description
ICD Codes International Classification of Disease (ICD) codes are used in the Geisinger system to classify procedures, exams, and other patient encounters. They are used for diagnosis and billing purposes
Social History Information relevant to social and behavioral determinants of health are captured within the Social History section of the electronic health record. Information captured includes patient smoking status and other substance use/abuse history, as well as the date this information was recorded within the health record
Demographics Patient age, sex, race, gender, employment status, and address are available as part of the health record
Surveys Captured as Part of Clinical Care Patients may be asked to complete surveys regarding aspects of their health at various appointments and visits while a patient at Geisinger. The name, description, version, and date of the survey are all stored in the medical record. Examples include the PHQ-2, a depression screener, which is captured on every patient during regularly scheduled primary care appointments. Other department-specific surveys include patient-reported pain scales captured during clinic visits for interventional pain treatment and Addiction Severity Index scores captured as part of substance abuse treatment
Prescription Data (from within and outside of Geisinger) The medical record houses medication administration information, including drug name, dose, route and location of administration. Information is also available for medication dispensed outside of Geisinger via Surescripts2 (which is a health information network used by doctors, pharmacists, EHR companies, etc.). Surescripts data is normally pulled overnight or upon demand by a Geisinger provider. Upon request, it pulls back around 24 months of prior medication dispensed information
Procedures and laboratory results There are procedure orders and procedure results available in the EHR, including surgical and non-surgical procedures. Information available includes the specific procedure that was ordered, description of the procedure order, and the type of procedure order. Procedure results also include lab results, whether the lab result was abnormal and type of abnormality, etc
Insurance claims Which insurance company a patient has used for their Geisinger care is documented and accessible. Geisinger also has its own insurance company, Geisinger Health Plan (GHP). If a patient is insured with GHP (~ 30% of Geisinger patients), information for each patient claim with the insurance company and details surrounding that claim are available, thus capturing claims that may occur outside of Geisinger facilities
Brain Imaging Access to brain imaging (including MRI and CT) is possible using the Geisinger EHR. This clinical data available includes the reason for the ordered imaging, date of diagnosis related to the imaging, findings, etc. Brain imaging information can be linked to the other health record information for each patient generate a more comprehensive health data overview for these patients