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How EHR-based assessment tools may
assist practitioners in general medical
settings in providing coordinated SBIRT
for SUD & other medical care
Christopher Shanahan MD MPH FACPBoston University School of Medicine
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Build it Better, Implement it Right
7/31/2014
CW Shanahan
Objectives
Development & Design
Workflow
Clinical Decision Support
Future EHR-enabled SBIRT
Implementing EHR-enabled SBIRT
Implementation: “It all Depends”
Supporting change
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Development Assess current practice
Determine scope
Identify requirements / use cases
Devise workflow logic
Create & use standards
Identify barriers & opportunities
Develop efficient & effective user interface
Ensure workflow / system adaptability
Develop & support clinician training
Establish feedback channels / user groups
Establish clinical benchmarks
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NIDA CTN EMR Project: Implications of Adopting Standardized Core
Data Elements in Health Systems of Drug-Abuse Treatment Providers
Ghitza U, Lindblad R, Gore-Langton R, Sparenborg S, Tai, B
All EHRs are not equal
Differ in Capacity to …..
Configure data collection Forms
Enforce data Integrity
Deliver provider alerts
Provide/configure clinical decision support
Integrate/interoperate/exchange data with other
systems
Permit modifications to EHR without requiring
vendor involvement
Etc.
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Design Matters
Form improves function
• Increases productivity
• Leads to better documentation & data quality
• Standards improve usability, interoperability, ease training
• Informs better decision making
• Provides training at point-of-care when most needed
• Unified presentation helps ensure fidelity of “meaning”
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Data Acquisition Screening & Assessment
Who will do it? Multimodal Technology / Multiple Staff
Patient
Paper/Kiosk/Tablet/Mobile/Web/Telephony/etc.
Can require, Needs verification
Staff
Paper/PC/Tablet/etc.
Can require
Clinician
PC/Tablet/etc.
May or may not require
Where to be done physically & in EHR workflow? Workflow & EHR system dependent
Standardized Questions/instruments / Data elements
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Workflow
Data Acquisition
Screening - Single Questions
•Tobacco
•Alcohol
•Drugs
•Prescription Medications
•Who Collects? (PT/STAFF/PROVIDER)
•How Collected? (Paper/Tablet/Kiosk/PC/Telephone/Mobile/Web)
•Where Collected? (Out of Clinic / Reception / Exam Room / etc.)
Data Acquisition
Assessment Instruments
•ASSIST
•DAST
•Who Collects? (PT/STAFF/PROVIDER)
•How Collected? (Paper/Tablet/Kiosk/PC/Phone/Mobile/Web)
•Where Collected? (Out of Clinic / Reception / Exam Room / etc.)
Decision Support
•EHR - Based
•Assessment
•Recommendations
Actions
•Automated
•Brief Intervention
•Referral to Treatment
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Decision Support
What to ask and how to ask it.
How to interpret & respond to answers.
Provide accessible educational tools using
Just-in-Time, Point-of-Care training
Evidence-based & Standardized
Practice guidelines
Assessments
Recommendations
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Acting on Decisions Data collected by others enables automated assessment.
Provider need only review & validate recommendations.
Act on recommendations
Actionable decision support tailored to the local environment
Automated Ordering
ePrescribing, CPOE, Referral (BI / RT - Staff / Clinician)
Facilitate Treatment / Referral to Treatment
Care Coordination
Engage, Educate & Monitor Patients
Tracking, monitoring, treatment planning
Quality Measures
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Make it easy to do the right thing
Clinical Decision Support
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
“System features that predict improved clinical practice”
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Future EHR Cognitive support
Effective Interface, Fits Workflow (physical & cognitive), Actionable
Information synthesis & sense-making Optimized balance of Structured versus narrative documentation
Teamwork & Communication Support Collaborative & Coordinated Care
Interoperability Shared meaning, Reusable & Transmissibility
Data availability Accessible & Useable
Interface usability
Customization Accommodate varied cognitive approaches
Managing information Filtering & highlighting key clinical data
Saleem JJ, et.al. JAMIA 2013 The next-generation electronic health record:
perspectives of key leaders from the US Dept. of Veterans Affairs11 7/31/2014
CW Shanahan
Ideal EHR-enabled SBIRT Tools
Standard, adaptable data models permits Platform
agnostic EHR dissemination/implementation
CDE Standardization
Adaptability / Customizable
Supports Intervention (BI & RT)
Facilitates tailored intervention
Provider intervenes at appropriate level
comfortable, capable/competent, convenient
Easily facilitates referral
Automated communication releases / consenting
Support patient tracking (Intra- & extra-institutional)
Facilitate follow-up with SUD treatment providers.
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Data Assess Advise Act
BI
RT
Reporting
Feedback
Delegate
Enhancing the SBIRT Workflow
Optimizing the SBIRT Workflow
Sustainability
Billing
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Next Generation SBIRT Coordination
Enabled by standardized core data elements &
assessment instruments that ensure standard
definitions & data meaning
Create confidential & secure clinical messaging that
facilitates transmission of referrals, care planning,
knowledge-sharing, etc... between & among
organizations.
Next generation secure messaging should be
interoperable and scalable via Health Information
Exchanges a/o Free-standing EHR systems.
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Successful implementation depends on many factors
Design / Development
Setting / Workflow (Model)
Organizational Culture / Provider
Characteristics
Introduction/Engagement
(Process)
Implementing EHR-enabled SBIRT
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Implementation Science
Study of methods promoting uptake of research
findings.
Research findings/innovations from small scale pilot/lab
often assumed generalizable and easily rolled out into
practice with little modification.
Studies challenges faced when generalizing research
findings to real world practice.
Key focus is fidelity - degree to which an
intervention or program is delivered as intended.
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Fidelity of Translation
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Translating Evidence-Based
Methods & Tools into Practice
Implementation science findings Help determine optimal approaches to develop & put into
operation a standardized clinical infrastructure that integrates:
Evidence-based clinical best-practices
Supports SUD research
Uses cases - How to:
Prevent established program lose effectiveness over time.
Prevent or prepare for unintended effects when tested programs are transferred to a new setting?
Effectively combine multiple interventions to:
Be more cost effective?
Reduce creation of new disease-specific program silos?
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Implementing an EHR Tool Workflow integration / adaptation - Critical to success
Workflow = Time, Work & Utility
Takes more time, creates more work, provides no utility - Will Fail.
Can all or part of provider burden be delegated?
If not, how & when can some be?
Excellent workflow is necessary but not sufficient
SBIRT Mission embraced by providers & supported by practice.
Fiscal incentives must be aligned (i.e. billing)
Account for multiple & competing goals
Best clinical practice, Billing, Team Care, Practice Improvement,
Meet Research Needs
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Understanding the Setting / Culture
General Medical Settings ≠ Treatment Settings
Low prevalence unhealthy substance use ~80%
Negative
Providers have:
Competing clinical priorities & No Time
Little / No training in SUD or SBIRT
Typically unwilling to open “Pandora’s Box”
Little / No Support (Social Worker / Treatment
Counselor)
Organizational priorities often not aligned
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Implementation Lessons
Providers are unlikely to screen or input data
(don’t base data collection strategy on it.)
Focus, expertise, standards & tools not enough
Both provider/practice willingness & operational
capacity required.
“The ground must be fertile”
SBIRT must fit seamlessly into existing workflow
Sustainability develops over time via cultural shifts
informed by feedback
production reports, positive results & experiences.
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Implementation: Key Dependencies 1: Workflow Model
Map existing develop future
Determine Workflow / Codify operations & Teamwork / Clarify Roles
2: EHR
Acceptance, User experience, Feature set, Capacity for / cost of enhancement, & Vendor
3: Development Process (Establishing need, feasibility & capacity)
Identify & assess organizational leadership, structures & key stakeholders/partners
Build demand (A need to do…)
Work with Developers (Public/Private - Academic / Commercial Vendor)
5: Interface Design / Usability
4. Implementation Approach (Organization culture & Effective processes)
6: Provider / Staff preparedness (Engagement, ownership, training & support)
7: Resources (Project manager, staff, time, money & assets)
8: Ongoing feedback
EHR Clinicians - (Clinical Performance Reporting)
Clinicians EHR/IT/Organization - (Ongoing process & interface improvement)
9: Patient education, engagement, & monitoring
10: Reengineering practice / Existing organizational initiatives
11: Unanticipated barriers & opportunities
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Supporting Change
Implementing EHR-enabled SBIRT
Maximize adoption opportunities by
lowering effort to change by providing:
Standard substance use knowledge set
key data elements
state-of-the-art screening instruments
Technological EHR development standards
Scientifically informed implementation best
practices
Clinical decision support training & content
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Summary Involve the provider as little as possible
Make it easy to do the right thing
Useful actionable decision support necessary but insufficient to ensure success, must also not increase time or work
Align all incentives (Performance, financial, etc.)
Define & adhere to standards for meaning, structure, & interoperability
Engage the organization: Leadership, management & staff
When implementing process matters
Change culture by engaging from the ground up
Provide feedback (Show people what they are doing)
Receive & respond to feedback to improve the system
Anticipate & support change, plan to adapt.
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