EHR Modification

Modifying your organization's electronic health record to support SBIRT can accelerate your patient flow, reduce the burden of data collection, and allow you to monitor and measure the success of your SBIRT implementation.

Key Data

For each patient, there are three key data points to collect.

1. Prescreening Results

For each prescreening question, record whether the patient was positive or negative. For example, a patient might score "Alcohol=Positive" and "Drugs=Negative".

2. Screenings Scores

For each full screening that was administered, such as the AUDIT, DAST10, or PHQ9, record the screening score and the recommended treatment indicated by that score. A patient might score "AUDIT=9, Brief Intervention" and "DAST10=5, Brief Treatment", because the AUDIT recommends a brief intervention for scores between 7 and 15 and the DAST10 recommends a brief treatment for scores between 3 and 5. The PHQ9 score does not correlate to a recommended treatment, and so only the score needs to be recorded for that instrument.

3. Treatment Provided

Record the service that the clinician provided to the patient. This could be "Education", "Brief Intervention", "Brief Treatment", or "Referral to Treatment". The service provided does not have to be the same as the treatment recommended by the screening scores.

Data Usage

In the SBIRT process, the prescreening results determine which full screenings should be administered, and then the full screening results determine which treatment is recommended. Each step depends on the results of the previous one, and so communication between staff members is critical. Adding the key SBIRT data points into easily accessible areas of the EHR can facilitate communication and reduce errors in the SBIRT process.

Outcome Measures

Outcome measures can be calculated from the data points, revealing how well your SBIRT process is operating. When analyzing your SBIRT data for a certain time period, consider calculating these six metrics:

1. Number of patients in target population

This is the number of people in that time period who should have been prescreened.

2. Prescreen Capture Rate

Prescreen Capture Rate = (number of patients who were prescreened) / (number in the target population). Prescreen capture rate measures the effectiveness of your prescreening system. When launching SBIRT, set a realistic goal, perhaps 80%, and work toward it.

3. Number and percentage who prescreen positive

The percentage of patients who prescreen positive demonstrates the size of your population's substance use problem. The number of positive prescreens is used in later calculations.

4. Screening Capture Rate

Similar to the prescreened capture rate, Screening Capture Rate = (number of patients who were screened) / (number who prescreened positive). This percentage indicates the effectiveness of your screening system.

5. Number and percentage who screen positive in each treatment category

Using patient's screening scores, calculate how many patients scored in each treatment category ("Education", "Brief Intervention", "Brief Treatment", and "Referral to Treatment"). These percentages indicate the proportion of patients at each risk level.

6. Intervention Capture Rate

Intervention Capture Rate = (number of patients who received an intervention) / (number who scored "Brief Intervention" or higher on a screening instrument). This ratio measures your effectiveness in actually getting help to those who need it. It is critical to set a goal for this ratio and monitor it regularly.

Automating Outcome Measures

A software package called SBIRT Dash has been used by some healthcare organizations to calculate these outcome measures automatically. You can learn more at the manufacturer's website.

Prescreen Scheduling

One final EHR modification is to set up an "alert" system to let your staff know when a patient should or should not be prescreened. Each patient should be prescreened during only one visit per year. Your staff need a mechanism to inform them which visits should be prescreened. There are three common methods for handling prescreen scheduling:

1. Date Field

Each time a patient is prescreened, record the date. When a patient returns for another visit, only prescreen that patient if a year has passed since that date.

2. Timed Alerts

Each time a patient is prescreened, create a timed alert that will trigger one year in the future. Only conduct the prescreen if the alert triggers.

3. Annual Exam

Only conduct SBIRT during annual exams. A patient will be prescreened at most once per year. However, you will miss all patients that do not regularly attend annual exams.

Cost Sharing

Adding screening instruments like the AUDIT or DAST10 to your EHR can be expensive. Inquire with your EHR vendor if other users have already paid to have those tools developed. If so, the vendor may accept a reduced fee to activate those instruments in your EHR.

Video Walkthrough

A webinar on integrating SBIRT into your patient flow is available here. This video provides additional options and suggestions for modifying your EHR.

E-mail: sbirt@indiana.edu
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