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Shanahan tdg sig meeting 3 15-11 v2.1
1. Implementation of Electronic
Screening and Clinical Support
into General Outpatient
Medicine Practices
Christopher Shanahan MD MPH
christopher.shanahan@bmc.org
Boston Medical Center
National Drug Abuse Treatment-CTN / TDG-SIG - 3/15/2011 1
2. Objectives:
• Current state: The Informatics of Substance Use
• Experience / Lessons learned from
implementing SBIRT in Non-research / Primary
Care settings
• Key Issues: Implementing IT innovation in
Primary Care Settings
• How can NIDA help General Medical practices
implement SBIRT and facilitate development &
implementation of Clinical Decision Support?
6/30/2015 2National Drug Abuse Treatment-CTN / TDG-SIG - 3/15/2011
4. • Clinical Core Substance use data-set lacking.
• Poor data poor reporting (Garbage in – Garbage out)
• Even when accurate, lack of standardized Substance
Use Ontology, makes it difficult or nearly impossible to
reliably use that data for clinical use, QI, or research.
• EHR systems generally lack care management /
registries for chronic disease management
• Many EHR systems lack real-time, evidence-based
clinical decision support
Despite electronic capture of clinical Substance Use data…
because captured data is not standardized,
capacity to employ this data continues to lag…
6/30/2015 4National Drug Abuse Treatment-CTN / TDG-SIG - 3/15/2011
5. Experience / Lessons
learned from implementing
SBIRT in Non-research /
Primary Care settings
6/30/2015 5National Drug Abuse Treatment-CTN / TDG-SIG - 3/15/2011
6. Massachusetts SBIRT (MASBIRT)
• Based on the Health Promotions Advocate (HPA) model
• Key Objectives:
1. Universal screening of large numbers of persons
2. Meet SAMHSA data collection/follow-up requirements
To support objectives…
Designed & built a web-based, screening & tracking
application optimized to integrated into clinical workflow.
6/30/2015 6National Drug Abuse Treatment-CTN / TDG-SIG - 3/15/2011
7. Typical General Medical Settings are
Distinct from Treatment Settings
• Low prevalence:
~80% Negative for harmful EtOH or Substance Use
• Competing Priorities / No time
• Little or No Provider/Staff Training
• Providers often unwilling to open Pandora’s Box
• Little or No Support (SW or Treatment Counselor)
• Misaligned Financial Incentives
6/30/2015 7National Drug Abuse Treatment-CTN / TDG-SIG - 3/15/2011
8. • Web-based and device independent (PCs, wireless tablets)
• Centrally located and managed (no data on devices)
• Seamless integration with existing data sources
• Optimized to Point-of-Care workflow
Dynamic work-lists “Hotlist”, Search-n-Screen, Follow-up/Tracking tools
• Flexible, efficient, accurate, and non-obtrusive data collection
Point and click application – near zero typing
• Maximal data integrity (build-in rules enforced)
• Master Patient Index eliminated redundant screening
• Real-time management /productivity reporting
• Automated data reporting to SAMHSA
• HIPAA compliant, secure
MASBIRT and IT Infrastructure Designed for
General Medical Settings/Primary Care
6/30/2015 8National Drug Abuse Treatment-CTN / TDG-SIG - 3/15/2011
9. The Result
• 117,000+ individuals screened over last 4 years at 3
distinct Hospital systems in the Inpatient, Outpatient,
Emergency Rooms and 5 FQHCs.
• After Screening scored, risk information/recommendations
provided to Primary Care provider via Provider
Communication Form (PCF).
o Paper given to the PCP, then filed with Medical Records for
scanning to the medical record.
o Electronic Document to HER
o Direct entry via EHR Form.
• Separate document
• Or part of the PCP visit note
6/30/2015 9National Drug Abuse Treatment-CTN / TDG-SIG - 3/15/2011
10. Data Collection & Handling
• Providers don’t screen or input resultant data.
• Provider Communication Form (PCF) containing
screening results given to Provider during visit.
• Tailored recommendations presented with
Screening results (PCF)
• PCF data stored in EHR / Viewed by all providers
• Documentation from subsequent Brief Intervention
a/o Treatment referral of patients screened (+)
stored in protected records
6/30/2015 10National Drug Abuse Treatment-CTN / TDG-SIG - 3/15/2011
11. Observations
• Several sites that were not systematically
screening came to understand and embrace
Universal Screening and are working to adopt
locally with or without HPA model in anticipation
of the project end.
• One practice already screening, MASBIRT
presence helped enhance performance
(Positivity rates increased from 5% to 25-30%)
6/30/2015 11National Drug Abuse Treatment-CTN / TDG-SIG - 3/15/2011
12. Key Issues: Implementing
IT innovation in Primary
Care Settings
6/30/2015 12National Drug Abuse Treatment-CTN / TDG-SIG - 3/15/2011
13. Implementation Lessons
• Providers won’t perform screening or input data (so don’t base the
data collection strategy on it.)
• Focus, expertise, standards, & tools not enough, BOTH cultural
willingness AND operational capacity required.
“the ground must be fertile”
o Do not implement if willingness or capacity are lacking
• Even with willingness and capacity….
o Change must ALSO be unobtrusive/fit seamlessly into existing workflow.
• Sustainability “appears” to be generated over time by production
feedback & positive results.
o Wow!! We have more patients at risk than we ever thought!
o This is important and we need to keep doing something about it.
o Lets monitor this and make sure we keep doing it well.
o Et.al.
6/30/2015 13National Drug Abuse Treatment-CTN / TDG-SIG - 3/15/2011
14. All EHRs are not equal:
Differ in…..
• Configurability of Data collection Forms
• Capacity to enforce Data Integrity
• Capacity to provider alerts
• Capacity to provide/configure Clinical Decision Support
• Capacity integrate/interoperate/exchange data with other
systems both within and outside of the local health care
provider IT infrastructure / network
• Need for modifications to EHR requiring Vendor
involvement (may be obstacle).
6/30/2015 14National Drug Abuse Treatment-CTN / TDG-SIG - 3/15/2011
15. Design & Development
Must not substantially increase work
Less is more
Standards improve usability / decrease training
Form improves function
• Increased Productivity
• Leads to Better Documentation & Data Quality
• Leads to Better Decisions
• Provides in situ Training
User Interface: Principles for Effectiveness
6/30/2015 15National Drug Abuse Treatment-CTN / TDG-SIG - 3/15/2011
16. How can NIDA help General
Medical practices implement
SBIRT and facilitate development
& implementation of Clinical
Decision Support?
6/30/2015 16National Drug Abuse Treatment-CTN / TDG-SIG - 3/15/2011
17. Baseline Assumptions
• The goal is Screening not Assessment.
• Complicated Screening Instruments (i.e. Perfect) are not
acceptable and cannot be used.
• Acknowledge that workflow is critical & build tools that
can integrate into it easily.
• Operational Workflow (The order of things) &
Information Workflow (What is known by whom &
when) are not the same.
Interaction between them is important,
must be understood & developed.
6/30/2015 17National Drug Abuse Treatment-CTN / TDG-SIG - 3/15/2011
18. IT as a Strategy: Cost & Benefits
• Costs:
o Substantial Effort: Time, Planning, & Resources.
o Long-term strategy: Difficult to sustain given temporal
trends and local shifts in focus.
• Benefits:
o Not guaranteed; Dependent on execution
o Increasing data granularity enhances utility of
Reporting, QI, Research, & Decision Support .
o Unavoidable tradeoffs between efficiency & specificity
Only NIDA’s Leadership will make this possible
6/30/2015 18National Drug Abuse Treatment-CTN / TDG-SIG - 3/15/2011
19. How can NIDA become an Agent of
Change and support SBIRT in Practice?
• Support Providers who want to begin
SBIRT in their practices need standards
based on Best practices & Best Evidence.
• Maximize adoption opportunities by
lowering the effort required for change by
providing standards and tool sets.
o Standard Substance Use Knowledge Set (key data elements
and direct linkage to state-of-the-art screening instruments)
o Training & Content tailored for Clinical Decision Support
6/30/2015 19National Drug Abuse Treatment-CTN / TDG-SIG - 3/15/2011
20. Supporting SBIRT in Clinical Practice
Providers need to know…
• What to ask (Dataset Standards)
o Establish a Common SBIRT Dataset based on Best Evidence &
Practice tailored to Clinical Settings
• How to ask it (Training)
o Provide & Communicate accessible Toolkits & Just-in-Time training
at Point of Care (POC) based on Best Evidence & Practice
o EHR based tools must be simultaneously intuitive & educational
• What to do with the answer. (Decision Support)
o Develop & provide POC Clinical Decision Support (CDS)
recommendation that can be easily incorporated in to standard
electronic Decision support algorithms (e.g. ARDIN)
6/30/2015 20National Drug Abuse Treatment-CTN / TDG-SIG - 3/15/2011
21. Clinical Decision Support (CDS)
“System features predict improved clinical practice”
Provided automatically in clinician workflow. p<0.00001
Provided recommendations not only assessments. p=0.02
Provided at decision making at point of care. p=0.03
Computer-based. p=0.03
Kawamoto, et.al.
Nearly all (94%) systems possessing all 4 features
significantly improved clinical practice
6/30/2015 21National Drug Abuse Treatment-CTN / TDG-SIG - 3/15/2011
