An Assessment of Family History Information Captured in an Electronic Health Record.

Family history is considered a core element of clinical care. In this study we assessed the quality of family history data captured in an established commercial electronic health record (EHR) at a large academic medical center. Because the EHR had no centralized location to store family history information, it was collected as part of clinical notes in structured or free-text format. We analyzed differences between 10,000 free-text and 9,121 structured family history observations. Each observation was classified according to disease presence/absence and family member affected (e.g., father, mother, etc.). The structured notes did not collect a complete family history as defined by standards endorsed by the U.S. Agency for Healthcare Research and Quality; the free-text notes contained more information than the structured notes, but still not enough to be considered "complete." Several barriers remain for collecting complete, useful family history data in electronic health records.