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Narrowing the Research-Practice Divide in Evidence-Based Medicine with Adoption of Electronic Health Record Systems: Present and Future Directions

July 13-14, 2009
NIDA Meeting

NIDA Organizers:
Udi Ghitza, Ph.D.
Betty Tai, Ph.D.
Steven Sparenborg, Ph.D.
Michele Straus, R.Ph., M.S.

Meeting Purpose and Intent:

The aim of this two-day meeting was to explore the prospects and challenges of using electronic health record systems (EHR) to bridge the gap between specialized substance abuse treatment and mainstream medical care. This meeting examined logistical, privacy, regulatory, technical, and financial challenges of developing and implementing integrated compatible EHR systems in evidence-based behavioral research and healthcare settings with a special focus on addressing issues associated with substance abuse care.

Meeting Outcome, Emerging Themes:

Participants presented information demonstrating that EHRs can be used to:

  • Reduce costs, improve quality of care, and integrate care across multiple providers
  • Aid in guideline implementation and provide clinical decision support
  • Monitor outcomes and enhance clinical and population-based research, including adverse event reporting
  • Aid in billing, reimbursement, and other administrative processes in clinical care
  • Benefit patients, clinicians, administrators and researchers by streamlining and organizing health care delivery
  • Foster use of unique and complementary longitudinal experimental designs in clinical research to supplement the use of randomized clinical trials
  • Facilitate utilization of iterative outcome measures for assessment of different stages of relapse-recovery and the chronic condition model of addiction.

Participants also discussed barriers to implementing and using EHRs in clinical care and research. These barriers fall into two main categories: 1) EHR availability, standardization and interoperability, and data validation and 2) limitations of clinical users and treatment settings including the regulations and state requirements that impact their processes.

EHR system limitations

  • Many EHR systems are available but lack interoperability for health information exchange and compatibility with each other and complimentary essential systems such as reporting and reimbursement
  • Problems exist with source data, data from multiple sources, and proprietary EHR systems
  • Internal and external quality assurance processes are needed to validate data
  • Regulatory and functionality barriers using EHR-based data for behavioral and medical research
  • Differences in coding, patient input, and comprehensiveness make EHRs difficult for researchers to utilize as sources of clinical data for research purposes

Challenges in adopting and implementing EHRs in community-based addiction treatment settings:

  • Variability in information technology sophistication and computer literacy. Using data, quality, and process improvement, and outcome assessment are not current practice for many treatment agencies and staff
  • Treatment settings vary widely in approach, goals, and size. Treatment typically includes a broader range of clinical care than is typically managed in EHRs
  • Some approaches to substance abuse treatment may be less amenable to guideline-based care or database derived structure than medical practices
  • Privacy and regulatory concerns and constraints, including HIPAA and CFR 42 Part 2 stipulations
  • Financial and reimbursement issues regarding adopting functional EHR systems.

Agencies are often strapped for funds, limiting ability to spend on EHR infrastructure, initial training, maintenance, and user support.

Participants offered observations and recommendations to address these issues and plan next steps including:

  • EHR adoption and implementation requires a multidisciplinary approach with buy-in from clinicians, researchers, patients, payers, billing staff, administrators, policy makers, etc.
  • Integral to EHR development, learn what clinicians, administrators, and researchers need from an EHR to help them in their daily work and to carry out projects. Include mental health and substance abuse treatment facilities in this assessment.
  • EHR adoption and implementation should make use of
    • Existing and functioning open-source, non-proprietary systems in the public domain. VistA/ CPRS (Department of Veteran's Affairs), service-oriented architecture (SOA) CONNECT open-source tool developed by Department of Defense (DOD), and the National Library of Medicine's (NLM's) personal health record system that uses standard vocabularies are three examples.
    • Collaborations with National Data Infrastructure Improvement Consortium (NDIIC) could enable the use of Web Infrastructure for Treatment Services (WITs) to utilize open-source data systems that permit health information exchange between agencies.
    • Ongoing efforts to standardize terminology, reporting and systems at the federal and state levels.
  • Regulations at the state and federal level, especially those pertaining to privacy and confidentiality need update.
  • Implementation of EHR requires strong leadership, difficult resource allocations and problem-solving decisions to enhance IT infrastructure adoption and overcome barriers. NIDA is well positioned to provide needed leadership and voice to include the substance abuse community in the overall effort; HITSP has identified vulnerable populations as a priority.
  • When developing strategies regarding EHR implementation in community-based drug abuse treatment programs, incorporate practices that have been successfully used by the NIATx network to make process improvements in the management and delivery of addiction treatment service.
  • Practices and requirements that facilitate uptake of EHR systems need to be promoted at the state level. Uniform state and federal requirements may facilitate adoption of new EHR systems.
  • Development and implementation of EHRs should address how to communicate health information across different reimbursement systems in a multi-payer system and should develop common technical standards that permit interoperability of EHRs in this context.
  • Educate clinician, researcher, administrative, and policy-making leaders about benefits and availability of EHRs for substance abuse treatment agencies. Doing so may facilitate changing the culture in these agencies to support adopting EHRs.
  • Provide flexibility in the design of EHRs so they may be modified to meet treatment agency needs.
  • Evidence-based care and the resulting positive health outcomes will be benefited both by the information available from an EHR during the patient care process, and the utilization of the data collected to provide evidence of treatment success.

Next Steps:

  • Survey existing and functioning open-source, non-proprietary EHR systems in the public domain and assess how to make these systems compatible and interoperable with electronic data capture systems in community-based treatment and/or clinical trial research settings. Utilize a multidisciplinary approach with feedback from various stakeholders to ensure buy-in from clinicians, researchers, patients, payers, billing staff, administrators, policy makers, etc. Remember to provide flexibility in the design of EHRs so they may be modified to meet treatment and state agency needs.
  • Solicit help of the National Association of State Mental Health Program Directors (NASMHPD) that has a wealth of state data regarding behavioral health agencies and delivery services to establish contacts with stakeholders who may be interested in promoting EHR adoption and implementation in community-based behavioral health treatment programs. Solicit the help of Regional Health Information Organizations (RHIOs), multi-stakeholder organizations and workgroups offering expertise and experience on strategies for effectively fostering, implementing health information exchange with integrated compatible clinical data standards across regional networks.
  • Inform clinicians, other interested stakeholders and promote knowledge of the Medicare Payment Incentives for eligible professionals who are meaningful EHR users, as stipulated in the Health Information Technology for Economic and Clinical Health Act (or the HITECH Act) of ARRA. See: Health IT (HHS web sites) for details.

Participant list (PDF Format, 220kb)
Agenda (PDF Format, 200kb)

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