Clinical Workflow and Substance Use Screening, Brief Intervention, and Referral to Treatment Data in the Electronic Health Records: A National Drug Abuse Treatment Clinical Trials Network Study

Abstract

Introduction: The use of electronic health records (EHR) data in research to inform recruitment and outcomes is considered a critical element for pragmatic studies. However, there is a lack of research on the availability of substance use disorder (SUD) treatment data in the EHR to inform research. Methods: This study recruited providers who used an EHR for patient care and whose facilities were affiliated with the National Institute on Drug Abuse’s National Drug Abuse Treatment Clinical Trials Network (NIDA CTN). Data about providers’ use of an EHR and other methods to support and document clinical tasks for Substance use screening, Brief Intervention, and Referral to Treatment (SBIRT) were collected. Results: Participants (n = 26) were from facilities across the country (South 46.2%, West 23.1%, Midwest 19.2 percent, Northeast 11.5 percent), representing 26 different health systems/facilities at various settings: primary care (30.8 percent), ambulatory other/specialty (26.9 percent), mixed setting (11.5 percent), hospital outpatient (11.5 percent), emergency department (7.7 percent), inpatient (3.8 percent), and other (7.7 percent). Validated tools were rarely used for substance use screen and SUD assessment. Structured and unstructured EHR fields were commonly used to document SBIRT. The following tasks had high proportions of using unstructured EHR fields: substance use screen, treatment exploration, brief intervention, referral, and follow-up. Conclusion: This study is the first of its kind to investigate the documentation of SBIRT in the EHR outside of unique settings (e.g., Veterans Health Administration). While results are descriptive, they emphasize the importance of developing EHR features to collect structured data for SBIRT to improve health care quality evaluation and SUD research.

Automated detection of substance use information from electronic health records for a pediatric population

“…However, our analysis suggested that structured EHR data only documented 22.0% of screening results, consistent with the literature. 8–10 Despite its high performance, LRM alone was unable to capture substance use information comprehensively.…”

“…Studies of pediatric healthcare systems have suggested that substance use screening with adolescents is occurring, but documentation in patients’ electronic health records (EHRs) is often unstandardized and exists in unstructured clinical notes, rather than in structured data fields. 8–10 The complexity and intensity of retrieving substance use screening information from unstructured data has limited healthcare systems in supporting providers as they monitor substance use over time. 8 , 11 , 12 Some studies have proposed incorporating standardized screening protocols to streamline documentation, 6 , 13 which, however, does not entirely address the challenges of modifying pediatrician behavior, 14 documentation, 8 or outcomes.…”

“… 8–10 The complexity and intensity of retrieving substance use screening information from unstructured data has limited healthcare systems in supporting providers as they monitor substance use over time. 8 , 11 , 12 Some studies have proposed incorporating standardized screening protocols to streamline documentation, 6 , 13 which, however, does not entirely address the challenges of modifying pediatrician behavior, 14 documentation, 8 or outcomes. 15 With a lack of widespread adoption of standardized substance use screening and documentation in pediatric settings, 16 there is a critical need to develop an efficient and cost-effective approach to transform substance use information from EHRs to a reusable format that can be accessed and reviewed across providers and tracked over time.…”

Using a health information technology survey to explore the availability of addiction treatment data in the electronic health records: A National Drug Abuse Treatment Clinical Trials Network study

“…Patients' healthcare data collected from EHRs and connected health IT tools have been used to measure the progress or outcomes of such efforts through quality improvement processes, meaningful use requirements, and research studies (Centers for Medicare & Medicaid Services [CMS], 2020; FDA, 2019; Krumholz et al, 2016). There is an urgent need to make SUD treatment-related information available in real-world patient data (Wu et al, 2019). The findings from this study emphasize the need to improve the completeness of SUD treatment data in EHRs; design individualized, user-specific interfaces to enhance the delivery of SBIRT services for SUDs via EHRs and connected IT tools; and develop research-friendly tools to integrate patient care data from multiple sources.…”

“…Only after effective clinical data recording tools are developed and integrated into a retrievable EHR system can effective pragmatic research be conducted. This survey highlights the ongoing variability in accessing complete information for SUD research through EHR systems (Wu et al, 2019).…”