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.

BACKGROUND: Healthcare data from electronic health records (EHRs) and related health information technology (IT) tools are critical data sources for pragmatic clinical trials and observational studies aimed at producing real-world evidence. To unlock the full potential of such data to advance science, the data must be complete and in structured formats to facilitate research use. METHODS: A Health IT survey was conducted within the National Drug Abuse Treatment Clinical Trials Network (CTN) to explore information related to data completeness and presence of unstructured data (e.g., clinical notes, free text) for conducting the EHR-based research for substance use disorders (SUDs). The analysis was based on 36 participants from 36 facilities located in 14 states and affiliated with the CTN. RESULTS: The mean age of the participants (n = 34) was 48.0 years (SD = 9.8). Of the participants enrolled, 50.0% were female and 82.4% were white. Participants' facilities were from four census-defined regions (South 35.3%, Northeast 29.4%, West 20.6%, Midwest 11.8%, Missing 2.9%) and represented diverse settings. The EHR was used by all surveyed facilities including 17 different kinds of EHR platforms or vendors, and 17.6% (n = 6) of surveyed facilities also used a separate EHR for behavioral health care (e.g., SUD care). Paper records were also used by 76.5% of surveyed facilities for clinical care (e.g., for health risk appraisal questionnaires, substance use screening or assessment, check-in screening, substance use specific intervention/treatment or referral, or labs/testing). The prevalence of using a patient portal, practice management system, and mHealth for patient care was 76.5%, 50.0%, and 29.4%, respectively. CONCLUSION: While results are descriptive in nature, they reveal the heterogeneity in the existing EHRs and frequent use of paper records to document patient care tasks, especially for SUD care. The use of a separate EHR for behavioral healthcare also suggests the challenge of obtaining complete EHR data to support research for SUDs. Much EHR development, integration, and standardization needs to be done especially in regard to SUD treatment to facilitate research across disparate healthcare systems.

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.

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.