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Common Data Elements for Substance Use Disorders in Electronic Health Records: The NIDA Clinical Trials Network Experience.

Addiction 2013;108(1):13-8. [doi: 10.1111/j.1360-0443.2012.03876.x]

Udi E. Ghitza, PhD (Center for the Clinical Trials Network, NIDA), Robert E. Gore-Langton, PhD (EMMES Corporation), Robert Lindblad, MD (EMMES Corporation), David Shide, PhD (EMMES Corporation), Geetha A. Subramaniam, MD (Center for the Clinical Trials Network, NIDA), Betty Tai, PhD (Center for the Clinical Trials Network, NIDA).

Electronic health records (EHR) are essential in improving quality and enhancing efficiency of health-care delivery. By 2015, medical care receiving service reimbursement from US Centers for Medicare and Medicaid Services (CMS) must show "meaningful use" of EHRs. Substance use disorders (SUD) are grossly under-detected and under-treated in current US medical care settings. Hence, an urgent need exists for improved identification of and clinical intervention for SUD in medical settings. The National Institute on Drug Abuse Clinical Trials Network (NIDA CTN) has leveraged its infrastructure and expertise and brought relevant stakeholders together to develop consensus on brief screening and initial assessment tools for SUD in general medical settings, with the objective of incorporation into US EHRs. Stakeholders were identified and queried for input and consensus on validated screening and assessment for SUD in general medical settings to develop common data elements to serve as shared resources for EHRs on screening, brief intervention, and referral to treatment (SBIRT), with the intent of supporting interoperability and data exchange in a developing Nationwide Health Information Network. Through consensus of input from stakeholders, a validated screening and brief assessment instrument, supported by Clinical Decision Support tools, was chosen to be used at out-patient and general medical settings. The screening instrument consists of a single question, "How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?" (developed and validated by Smith et al, Arch Intern Med 2010:170:1155-60), and the 10-item version of the Drug Abuse Screening Test (DAST) serves as the assessment tool for those who screen positive for potential SUD.

Conclusions: The creation and adoption of a core set of validated common data elements and the inclusion of such consensus-based data elements for general medical settings will enable the integration of SUD treatment within mainstream health care, and support the adoption and "meaningful use" of the US Office of the National Coordinator for Health Information Technology (ONC)-certified EHRs, as well as CMS reimbursement. (Article (Peer-Reviewed), PDF, English, 2012)

Keywords: Common data elements | Drug Abuse Screening Test (DAST) | Electronic health records (EHR) | Integrated medical and behavioral health care | Screening and assessment instruments | Screening, Brief Intervention, Referral to Treatment (SBIRT) | Addiction (journal)

Document No: 819, PMID: 22563741.

Submitted by CTN Dissemination Librarians, 5/8/2012.

Ghitza, Udi E. search mail
Gore-Langton, Robert E. search
Lindblad, Robert search mail
Shide, David search
Subramaniam, Geetha A. search mail
Tai, Betty search mail

Supported by a grant from the National Institute on Drug Abuse to the University of Washington Alcohol and Drug Abuse Institute.
The materials on this site have neither been created nor reviewed by NIDA.
Updated 8/2012 --