Integrating information on substance use disorders into electronic health record systems.

For reasons of safety and effectiveness, many forces in health care, especially the Affordable Care Act of 2010, are pressing for improved identification and management of substance use disorders within mainstream health care. Thus, standard information about patient substance use will have to be collected and used by providers within the electronic health record systems (EHRS). Although there are many important technical, legal, and patient confidentiality issues that must be dealt with to achieve integration, this article focuses upon efforts by the National Institute on Drug Abuse and other federal agencies to develop a common set of core questions to screen, diagnose, and initiate treatment for substance use disorders as part of national EHRS. As part of this effort, NIDA tasked its Clinical Trials Network (CTN) to lead the initiative to develop a set of standard common data elements (CDEs) that could become part of the EHRS, with the goal of helping to foster research on, and advance the practice of, screening, brief intervention, and referral to treatment (SBIRT) for patients with substance use problems. This article discusses the background and rationale for these efforts and presents the work to date to identify the questions and to promote information sharing among health care providers.

An article summarizing this paper, “Substance use must be included in electronic patient records: Study,” was published in the January 23 issue of Alcohol & Drug Abuse Weekly (vol. 24, issue 4). A response to that piece, “Commentary: CSAT’S Clark rebuts McLellan-Tai article,” was published the following week in ADAW, vol. 24, issue 5. To request these pieces, please email the Library at info@ctndisseminationlibrary.org.