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Abstract

Background:

Electronic health records (EHRs) are a promising new source of population health data that may improve health outcomes. However, little is known about the extent to which social and behavioral determinants of health (SBDH) are currently documented in EHRs, including how SBDH are documented, and by whom. Standardized nursing terminologies have been developed to assess and document SBDH.

Objective:

We examined the documentation of SBDH in EHRs with and without standardized nursing terminologies.

Methods:

We carried out a review of the literature for SBDH phrases organized by topic, which were used for analyses. Key informant interviews were conducted regarding SBDH phrases.

Results:

In nine EHRs (six acute care, three community care) 107 SBDH phrases were documented using free text, structured text, and standardized terminologies in diverse screens and by multiple clinicians, admitting personnel, and other staff. SBDH phrases were documented using one of three standardized terminologies (N = average number of phrases per terminology per EHR): ICD-9/10 (N = 1); SNOMED CT (N = 1); Omaha System (N = 79). Most often, standardized terminology data were documented by nurses or other clinical staff versus receptionists or other non-clinical personnel. Documentation ‘unknown’ differed significantly between EHRs with and without the Omaha System (mean = 26.0 (standard deviation (SD) = 8.7) versus mean = 74.5 (SD = 16.5)) (p = .005). SBDH documentation in EHRs differed based on the presence of a nursing terminology.

Conclusions:

The Omaha System enabled a more comprehensive, holistic assessment and documentation of interoperable SBDH data. Further research is needed to determine SBDH data elements that are needed across settings, the uses of SBDH data in practice, and to examine patient perspectives related to SBDH assessments.

Keywords

Social determinants of health behavioral determinants of health electronic health records Omaha System nursing terminologies

Social and behavioral determinants of health (SBDH) are critical and actionable elements of a comprehensive, holistic patient assessment to ensure optimal healthcare treatment and outcomes.^1–5 There is an urgent call to collaborate in policy and business toward coordinated action, using health information technology, specifically electronic health records (EHRs), as a unifying data source.⁵ Ensuring standardization and interoperability of SBDH data is essential to bridge gaps in SBDH information exchange across systems and settings.^4–11 Toward that end, the Institute of Medicine (IOM) was charged with defining measures to capture SBDH universally in EHRs.⁴ However, little is known about the extent to which SBDH phrases are currently captured within EHRs. The goal of this comparative study was to understand how SBDH are documented as a first step toward advancing the use of EHR-generated SBDH data as both clinical and population health data resources.

Populations that are poor and underserved suffer disproportionately from unfair and avoidable health disparities due to the inequitable distribution of resources.^10–15 Achieving optimal health for these populations depends on understanding and acting on determinants of health that go beyond traditional biomedical care, commonly referred to as SBDH.^1–15

Social determinants of health are the environmental context and social conditions in which people live.¹⁰ Behavioral determinants of health are not seen as simply individual choice but rather are defined as individual responses to disease that are shaped by social forces that influence health.¹⁶ Thus SBDH are linked in a circular fashion in which social and environmental factors influence individual behaviors. Individual behaviors, in turn, impact pathways to health and disease outcomes which then influence the individual’s interaction with society and healthcare. Therefore, it is critical to examine SBDH as a comprehensive whole in order to understand the importance of context on health behavior and outcomes.¹⁶

The contribution of SBDH to personal and population health is well documented.^4,5,10,11 For example, in coronary artery disease, personal risk factors may include low-density lipoproteins and hypertension; social risk factors may include poverty and lack of social support; and behavioral risk factors may include physical inactivity and smoking. The interventions to address SBDH are likewise multifaceted. While acute and ambulatory interventions may focus on individual medical care directed toward managing lipid levels and blood pressure, public health interventions may use diverse strategies such as policy change to mitigate poverty, and social media campaigns to promote healthy lifestyle behaviors. Thus, to achieve optimal population health for coronary artery disease and most chronic conditions, it is essential to align and integrate care across all health sectors. Such integration of primary care, acute care, long-term care, and public health are essential for improving population health based on shared EHR data.^{1–5,10,11,17,18}

Necessary to the integration of optimal care is the ability to share data critical to the improvement of healthcare across all sectors. EHRs are a promising source of population health data that may improve health outcomes.^4–11,17 In a seminal article, Kukafka et al. (2007) argued that EHR redesign to include SBDH data was essential in order to ensure that EHR data could be reused for public health purposes and realize the potential of EHR data to improve population health.¹⁷ The US Centers for Disease Prevention and Control (CDC) reported exemplary emerging efforts to share SBDH information across settings for population health management in North Carolina, Minnesota, and Ohio.¹ Such efforts require the implementation of robust standards for patient assessments and data capture.^4–11 Toward expanding the use of EHR data, the Committee on the Recommended Social and Behavioral Domains and Measures for Electronic Health Records, the Board on Population Health and Public Health Practice, and IOM were charged with the task of recommending core SBDH measures that should be incorporated within EHRs.⁴ The final measures were race/ethnicity, tobacco use, alcohol use, and residential address, educational attainment, financial resource strain, stress, depression, physical activity, social isolation, intimate partner violence (for women of reproductive age), and neighborhood median-household income.⁵ The rationale given for selecting these measures was that all could be derived from standard, available measures of useful health information collected directly from patients through self-report.⁵

However, the IOM task force noted that many challenges exist to accomplish the shared goals of both improving clinical medicine and supporting public health surveillance and research. Among the challenges was the lack of a standardized method to routinely capture these data in EHRs.⁵ While the IOM recommended patient-reported measures for SBDH measures for universal capture in EHRs, federal rule specifies that standardized terminologies must be used in EHRs to ensure shared understanding and data interoperability.¹⁹ Thus, it is critical to understand the contribution of standardized terminologies as potential sources of SBDH data, particularly until all EHR systems have robust capacity for patient-reported measures. In addition, the IOM task force urged the protection of privacy in SBDH data collection, in particular for sensitive concepts such as substance abuse and mental illness.²⁰ The Health Insurance Portability and Accountability Act (HIPAA) allows healthcare providers to collect SBDH information when reasonably necessary for providing care, and to be shared as for individual treatment purposes.^20,21 However, other uses or disclosures not related to patient care may require the patient’s prior express authorization (HIPAA), thus potentially impeding the reuse of SBDH information in aggregate for population health improvement.²¹ The IOM committee examined the accessibility of the data from other sources such as in the US Census which currently cannot be smoothly integrated into an individual EHR, and thus these sources require duplicative documentation to achieve a population health dataset and provide data for clinical decision support at the point of care.⁵

Standardized terminologies

Standardized terminologies are designed for use in EHRs to ensure shared understanding and data interoperability.¹⁹ A subset of standardized terminologies has been recognized by the American Nurses Association, including Systematized Nomenclature of Medicine Clinical Terminology (SNOMED CT), Logical Observation Identifiers Names and Codes (LOINC), and several interface terminologies that are mapped within SNOMED CT and LOINC.²² Previous studies have shown that standardized nursing terminologies are a potential source of SBDH data in EHRs.²³ In particular, the Omaha System is a multidisciplinary terminology, standardized classification, and measure that serves as a comprehensive holistic assessment of health for SBDH documentation.²⁴ This highly developed, simple instrument exists in the public domain. It is organized in four domains representing an ecological framework that includes environmental, psychosocial, and health-related behavior aspects of health related to physiological health concepts.²⁴ It is mapped to SNOMED CT and LOINC and thus meets the criteria set forth in the Meaningful Use Rule. Public health departments use Omaha System data to share and compare population health outcomes.^23,24

Understanding and managing SBDH and all patient information is critical for high-quality healthcare and for improving population health, especially for the poor and underserved.^5,25 The theoretical foundation for the reuse of SBDH data in EHRs has been described; the compelling case for the uniform collection of SBDH data has been established; and national minimum data collection recommendations have been set forth.^5,16 However, little is known about how SBDH are currently documented in diverse EHRs, including how many SBDH are documented, in which screens, in what format, and by whom. The purpose of this comparative study was to examine the documentation of SBDH in EHRs in a convenience sample of EHRs for acute care, ambulatory care, and community-based care, with and without standardized terminologies.

Methods

This comparative study of SBDH documentation methods across EHRs was conducted using key informant interviews as a quality improvement project at the request of a state health department, and was deemed exempt from Institutional Review Board review. Graduate students (NK, JMR, and KW) in a population health informatics class conducted in-depth interviews of key informants representing a convenience sample of nine EHRs used in hospitals, clinics, and public health departments in the Midwest. We aimed to compare diverse EHRs due to the need to document SBDH in all EHRs for population health improvement. The study was completed in the period of time between publication of the first and second IOM reports.^4,5

Sample

Health- and information-system leaders with EHR domain expertise who were known to the study team were invited to provide data for the quality improvement project. Representatives of nine EHRs agreed to participate. Up to three individuals were interviewed for a single EHR. The nine EHRs represented eight different EHR vendors with instances in nine different health systems/locations, and included the most commonly used EHRs in the region. Six were in acute care or ambulatory systems (Allscripts, Epic (two different systems), EpicCare Ambulatory, Meditech, and custom software), and three were in public health/home health/community care systems (CareFacts, CHAMP, and PH Doc).

Scoping review of the literature

A review of SBDH scientific literature, web sites, and health services resources such as state health department web sites and national recommendations was conducted by the three graduate students. The keywords were social determinants, health, and health determinants. Further search terms and articles were explored based on findings from the initial searches. From a search of PubMed, Cinahl, google scholar, and official web sites (US CDC,¹⁰ US IOM,^4,5 World Health Organization¹¹), 20 resources were examined in detail, yielding 107 unique SBDH phrases. These 107 phrases were grouped into the 17 SBDH topics identified in IOM Phase 1 study, and an additional seven topics from the literature review, for a total of 24 SBDH topics. The 107 phrases were added to a google docs spreadsheet as a data collection tool for key informant interviews.

Interviews

Interviews were scheduled at the convenience of the key informants during telephone, skype, or face-to-face conversations with one of three graduate students. Graduate students asked key informants if and how these phrases were documented in the EHR, and, if so, the role of the individual documenting the phrase and EHR screen in which the item was documented. In addition, the key informants were asked to identify whether or not a standardized terminology was used to represent the phrases. Standard descriptive and inferential statistics were conducted using Excel 2010 and SPSS v. 22.

Post hoc mapping of SBDH and IOM phrases to standardized terminology

Due to the high frequencies of SBDH phrases documented using the Omaha System discovered in this study, a formal mapping of the 107 SBDH phrases to Omaha System problem terms was conducted post hoc for analysis by the authors (KAM, SM, ES) to evaluate the value of using the Omaha System to document SBDH in EHRs.

Instrument

The Omaha System consists of three valid, reliable instruments: Problem Classification Scheme, Intervention Scheme, and Problem Rating Scale for Outcomes, related by a shared structured problem list of 42 concepts.²⁴ These concepts are arranged taxonomically in four domains: environmental, psychosocial, physiological, and health-related behaviors, as shown in Table 1. The problems are defined and each has a unique set of signs/symptoms.

Table 1.

Omaha System Problem Concept Definitions by Domain.

Domain	Concept	Definition
Environmental	Income	Money from wages, pensions, subsidies, interest, dividends, or other sources available for living and healthcare expenses
Environmental	Sanitation	Environmental cleanliness and precautions against infection and disease
Environmental	Residence	Living area
Environmental	Neighborhood/workplace safety	Freedom from illness, injury, or loss in the community or place of employment
Psychosocial	Communication with community resources	Interaction between the individual/family/community and social service organizations, schools, and businesses in regard to services, information, and goods/supplies
Psychosocial	Social contact	Interaction between the individual/family/community and others outside the immediate living area
Psychosocial	Role change	Additions to or removal of a set of expected behavioral characteristics
Psychosocial	Interpersonal relationship	Associations or bonds between the individual/family/community and others
Psychosocial	Spirituality	Beliefs and practices that involve faith, religion, values, the spirit, and/or the soul
Psychosocial	Grief	Suffering and distress associated with loss
Psychosocial	Mental health	Development and use of mental/emotional abilities to adjust to life situations, interact with others, and engage in activities
Psychosocial	Sexuality	Attitudes, feelings, and behaviors related to intimacy and sexual activity
Psychosocial	Caretaking/parenting	Providing support, nurturance, stimulation, and physical care for dependent child or adult
Psychosocial	Neglect	Child or adult deprived of minimally accepted standards of food shelter, clothing, or care
Psychosocial	Abuse	Child or adult subjected to nonaccidental physical, emotional, or sexual violence or injury
Psychosocial	Growth and development	Progressive physical, emotional, and social maturation along the age continuum from birth to death
Physiological	Hearing	Perception of sound by the ears
Physiological	Vision	Act or power of sensing with the eyes
Physiological	Speech and language	Use of articulated vocal sounds, symbols, signs, or gestures for communication
Physiological	Oral health	Condition of the mouth and gums and the number, type, and arrangement of the teeth
Physiological	Cognition	Ability to think and use information
Physiological	Pain	Unpleasant sensory and emotional experience associated with actual or potential tissue damage
Physiological	Consciousness	Awareness of and responsiveness to stimuli and the surroundings
Physiological	Skin	Natural covering of the body
Physiological	Neuro-musculo-skeletal function	Ability of nerves, muscles, and bones to perform or coordinate specific movement, sensation, or regulation
Physiological	Respiration	Inhaling and exhaling air into the body and exchanging oxygen
Physiological	Circulation	Pumping blood in adequate amounts and pressure throughout the body
Physiological	Digestion-hydration	Process of converting food into forms that can be absorbed and assimilated, and maintain fluid balance
Physiological	Bowel function	Transporting food through the gastrointestinal tract to eliminate wastes
Physiological	Urinary function	Production and excretion of urine
Physiological	Reproductive function	Condition of the genital organs and breasts and the ability to reproduce
Physiological	Pregnancy	Period from conception to childbirth
Physiological	Postpartum	Six-week period following childbirth
Physiological	Communicable/infectious condition	State in which organisms invade/infest and produce superficial or systemic illness with the potential for spreading or transmission
Health-related behaviors	Nutrition	Select, consume, and use food and fluids for energy, maintenance, growth, and health
Health-related behaviors	Sleep and rest patterns	Periods of suspended motor and sensory activity and periods of inactivity, repose, or mental calm
Health-related behaviors	Physical activity	State or quality of body movements during daily living
Health-related behaviors	Personal care	Management of personal cleanliness and dressing
Health-related behaviors	Substance use	Consumption of medicines, recreational drugs, or other materials likely to cause mood changes and/or psychological/physical dependence, illness, and disease
Health-related behaviors	Family planning	Practices designed to plan and space pregnancy within the context of values, attitudes, and beliefs
Health-related behaviors	Healthcare supervision	Management of the healthcare treatment plan by healthcare providers
Health-related behaviors	Medication regimen	Use or application of over-the-counter and prescribed/recommended medications and infusions to meet guidelines for therapeutic action, safety, and schedule

Mapping procedure

The first author created the initial mapping in which 20 problems mapped to the 107 SBDH phrases 155 times. This mapping was critiqued independently by the other two authors based on definitions and signs/symptoms of the problems. Each phrase was reviewed by the group, and differences were resolved by consensus. All three authors agreed on the problems identified in the initial mapping. Through the mapping validation process, additional problems (range = 1–4) were added for 30 (28.0%) of the 107 SBDH phrases (Figure 1). The value of mapping to a terminology became evident with redundant descriptions such as ‘Access to Health services—including clinical and preventive care’, ‘Access to Primary Care—including community-based health promotion and wellness program’ that may be documented differently depending on the EHR and differed in relationship to Omaha System problems. The complete mapping spreadsheet is available online.

Figure 1.

The 107 Social and Behavioral Determinants of Health phrases from the literature review were mapped to 26 Omaha System problem concepts 196 times. The original mapping is shown in light grey, with additions after expert review shown in darker grey.

Results

The 107 SBDH phrases were documented uniquely within each EHR using free text, structured text, and standardized terminologies (Table 2). The SBDH phrases were documented using one of three standardized terminologies (N = average number of phrases per terminology per EHR): International Classification of Diseases-9th revision or 10th revision (ICD-9/10) (N = 1), SNOMED CT (N = 1), and the Omaha System (N = 79). Most often, standardized terminology data (Omaha System, SNOMED CT, or ICD) were documented by nurses or other clinical staff versus receptionists or other non-clinical personnel. Documentation ‘unknown’ was much greater for EHRs without the Omaha System (26.0 (standard deviation (SD) = 8.7) with the Omaha System versus 74.5 (SD = 16.5) without the Omaha System) (p = .005). All three community care EHRs evaluated in this study allowed for documentation using the Omaha System, with similar documentation of SBDH across the three EHRs. Post hoc mapping of the 107 SBDH phrases to the Omaha System yielded 26 problems in four domains. A heat map of the post hoc mapping by topics and Omaha System domains is shown in Figure 2.

Figure 2.

Heat map showing mapping of Omaha System problems to Social and Behavioral Determinants of Health study topics by Omaha System Domain.

Table 2.

Frequencies and Percentages of Documentation Types for the 107 Social and Behavioral Determinants of Health Items

Type of documentation	Frequency	Percentage
Omaha System	79.0	73.8
Unknown	56.1	52.5
Not documented	32.0	29.9
Structured (not terminology)	17.1	15.1
Free text	10.3	9.6
Yes (documentation type not described)	6.0	5.5
ICD-9/10	1.0	0.9
SNOMED CT	1.0	0.9

ICD-9/10: International Classification of Diseases-9th revision or 10th revision; SNOMED CT: Systematized Nomenclature of Medicine Clinical Terminology.

Discussion

This is the first known study that compared the documentation of SBDH information across EHRs. Each of the nine EHRs uniquely captured a range of SBDH phrases in diverse ways by different observers, methods, screens, and terms. Having the Omaha System terminology embedded within the EHR greatly increased the number of standardized, retrievable SBDH phrases that were documented. The findings of this initial study suggest there is a need for further examination of SBDH documentation in EHRs across the continuum of healthcare settings.

Findings demonstrate that the goals of robust SBDH knowledge representation and interoperability have been met in a subset of the EHRs surveyed in this project through the implementation of the Omaha System, a comprehensive, holistic terminology used within the EHR as a central organizing principle and documentation framework.²⁴ This aligns with the intent of the Omaha System to enhance EHR capacity for multidisciplinary users to collect, store, organize, retrieve, and report comprehensive patient assessment data.²⁴ The finding that the mapping of SBDH in natural language related to 26 Omaha System problems in four domains (Figure 2) shows the extensive impact of SBDH on human health, and demonstrates the value of standardization for quality data documentation and interoperability.

Findings revealed that an informatics approach was successful in the extensive capture of SBDH data using standardized terminology, as compared to the IOM recommendations for using standardized measures.^5,19 These two approaches arise from disparate worldviews. The SBDH measures recommended by the IOM are grounded in the science of measurement; while the EHR certification standards are predicated on the notion that knowledge may be codified and classified by clinician observers.^5,19 Both worldviews may be bridged and expanded by leveraging the capacity of existing terminologies when mapped to patient-reported measures.²³ Given the long tradition of nursing terminology expertise,²² these findings suggest that methods aligning with nursing use of terminology standards may be leveraged to better assess, document, and communicate all aspects of patient health and well-being with all members of the healthcare team.

The finding of fewer responses of ‘unknown’ for the EHRs with the Omaha System suggests key informants had a greater understanding of how SBDH information was organized and managed in the EHRs with the Omaha System. The implications of a known and rationally structured data collection tool and process for SBDH documentation are many. Figures 3 and 4 (copyright Candice Garay and Karen Monsen) show the integration of standardized SBDH phrases with usual health assessments that are documented for a single patient (Figure 3) or a group of patients (Figure 4). The figures are examples of using the Omaha System in dashboard format using variation in hue and saturation to enable rapid interpretation and decision-making by all members of the healthcare team.

Figure 3.

Prototype dashboard of SBDH data for a single patient (copyright Candice Garay and Karen Monsen).

Figure 4.

Prototype dashboard of SBDH data for a patient group (e.g. by provider) (copyright Candice Garay and Karen Monsen).

The finding a clinician (nurse or other healthcare professional) versus a non-clinician (paraprofessional or administrative personnel) was more likely to document SBDH data using a standardized terminology likely relates to the type of documentation that occurs in community care settings versus acute care settings, in which the primary interaction with patients occurs when nurses or other clinicians conduct and document a comprehensive assessment. This finding is important because it aligns with the notion that to ensure patient safety and a high level of data privacy, sensitive SBDH information may be best elicited in a private, professional interview rather than at an admission desk.^5,20,25 Further, the implications of this study in the era of Accountable Care are several. The EHRs based on the Omaha System were used in community care settings where SBDH assessments and interventions are common. The data needed for care in community may differ from data needed in acute care setting. Further research is needed to determine SBDH data elements that are needed across settings. However, there is a growing need to communicate seamlessly during transitions between settings regarding a comprehensive plan of care in order to optimize both personal and population health, particularly when ensuring access and coordinating care for the poor and underserved.^1–3 Further research is needed to evaluate whether the methods that have been successful in community care may be applicable across settings,^26–28 examine the uses of SBDH data in practice, and to better understand patient perspectives related to SBDH assessments. Further research is also needed to examine the potential to use other standardized terminologies to capture SBDH data in EHRs.

There were a number of limitations to this project. First, it was not possible to conduct an exhaustive survey of all EHRs in the region; however, the EHRs sampled represented a broad spectrum of EHRs across the continuum of settings from community through acute care and included the most commonly used EHRs in acute, ambulatory, and community care. Second, this survey was conducted prior to national guidance regarding the collection of SBDH data in all EHRs; thus, the findings represent a baseline from which further research may be conducted on SBDH assessments which may reflect changes based on new SBDH documentation policy. Third, it is possible that key informants for community care EHRs may have been familiar with the use of the Omaha System to document important SBDH concepts, and potentially biasing findings regarding the use of the Omaha System to document SBDH concepts. However, such familiarity with structured documentation is essential for reliable data reuse, aggregation, and retrieval, and, therefore, is a critical competency expected for individuals who were key informants for all EHRs. Finally, our survey was based on a literature review that yielded 107 different questions, some of which differed slightly from other questions. Future studies should consolidate such questions, and evaluate the reliability of interviewers and responses in order to ensure the reliability of findings.

In response to the urgent call to collaborate in policy and business toward coordinated action,⁵ using EHRs as a unifying data source is currently being addressed by EHR vendors and healthcare providers.^12,17,23 Given the documentation burden of the current EHR and the fundamental need to improve care for the poor and underserved, it is critical to leverage the potential to reduce workload related to SBDH documentation and increase data value while improving documentation and data quality through the implementation of informatics solutions such as the Omaha System.²⁴

Conclusion

A comparative study of SBDH documentation in nine EHRs showed that the extent to which meaningful and retrievable SBDH data were documented differed vastly based on the presence of a standardized terminology. Specifically, the Omaha System enabled a more comprehensive, holistic, professional assessment and documentation of standardized interoperable SBDH data. This aligns with the intent of the Omaha System to enhance EHR capacity for multidisciplinary users to collect, store, organize, retrieve, and report comprehensive patient assessment data. Nursing expertise may be leveraged in assessing and communicating all aspects of patient health and well-being using standardized terminologies. Further research is needed to determine SBDH data elements that are needed across settings, to examine the uses of SBDH data in practice, and to better understand patient perspectives related to SBDH assessments.

Footnotes

Acknowledgements

This informatics-policy project was completed by University of Minnesota School of Nursing Doctor of Nursing Practice students and faculty at the request of the Minnesota eHealth Initiative – Minnesota Department of Health, and the University of Minnesota Center for Nursing Informatics. The authors thank Dr. Martin LaVenture and Dr. Candice Garay.

Authors’ contributions

All authors have contributed to the study and manuscript development.

Availability of data and materials

Available by request to the first author.

Declaration of conflicting interests

None declared.

Ethical approval

Deemed not human subjects research by University institutional review.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Informed consent

Not applicable.

ORCID iD

Karen A Monsen

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Appendix

Privacy concerns related to inclusion of social and behavioral determinants of health in electronic health records. In: Committee on the Recommended Social and Behavioral Domains and Measures for Electronic Health Records, Board on Population Health and Public Health Practice and Institute of Medicine (eds) Capturing social and behavioral domains and measures in electronic health records: phase 2. Washington, DC: National Academies Press, 2015, pp.319–335.

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Documentation of social determinants in electronic health records with and without standardized terminologies: A comparative study

Abstract

Background:

Objective:

Methods:

Results:

Conclusions:

Keywords

Standardized terminologies

Methods

Sample

Scoping review of the literature

Interviews

Post hoc mapping of SBDH and IOM phrases to standardized terminology

Instrument

Mapping procedure

Results

Discussion

Conclusion

Footnotes

Acknowledgements

Authors’ contributions

Availability of data and materials

Declaration of conflicting interests

Ethical approval

Funding

Informed consent

ORCID iD

References