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.

This is the primary outcomes article for CTN-0071-Ot.

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. This study recruited providers who used EHR for patient care and whose facilities were affiliated with the National institute on Drug Abuse’s National Drug Abuse Treatment Clinical Trials Network (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.

Participants (n=26) were from facilities across the country (South 46.2%, West 23.1%, Midwest 19.2%, Northeast 11.5%), representing 26 different health systems/facilities at various settings: primary care (30.8%), ambulatory other/specialty (26.9%), mixed setting (11.5%), hospital outpatient (11.5%), emergency department (7.7%), inpatient (3.8%), and other (7.7%). Validated tools were rarely used for substance use screening 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 screening, treatment exploration, brief intervention, referral, and follow-up.

Conclusions: 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.

Related protocols: CTN-0071-Ot