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Development of a Primary Care Guide for Implementing Evidence-Based Screening and Counseling for Unhealthy Alcohol Use With Epic-Based Electronic Health Record Tools: A Pilot Dissemination Project

Research Report
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These reports are available in PDF only (Methods Report [462.9 KB], Implementation Package [4.5 MB]). People using assistive technology may not be able to fully access information in these files. For additional assistance, please contact us.

This report is from AHRQ's series on Health Systems Partnership Pilot Project Reports. These reports describe the efforts of Evidence-based Practice Centers (EPCs) to work with health care decisionmakers and facilitate the use of information from AHRQ EPC evidence reports.

Key Messages

  • Findings: We evaluated the initial implementation of an evidence-based, systematic approach to screening and counseling for unhealthy alcohol use in a General Internal Medicine (GIM) Clinic that included Epic electronic health record (EHR) tools. Factors facilitating implementation included leadership support and organizational culture; a multidisciplinary team; and staff and provider buy-in. EHR tools increased service provision but could contribute to alert fatigue. Competing demands, a large patient population, and turnover in nursing staff and resident providers were identified as potential barriers. We then developed a dissemination package intended to offer a practical roadmap to the process of integrating these evidence-based services into a clinic’s workflow. Key Informants (representatives of health systems in a position to make decisions about implementation of services into primary care) viewed the package very favorably.
  • Lessons Learned for EPC Program: Developing dissemination packages based on Evidence-based Practice Center reports would require expansion of the timeline and resources. Creation of support tools would be facilitated by working with a team that has recently implemented the clinical service in question. Development of the dissemination package for the current pilot project was preceded by nearly 2 years in which we worked on implementation in the clinical setting.
  • Utility for Health Systems: Key Informants reviewed a draft of the package and completed a questionnaire about its usefulness. They found package components providing direct, practical guidance for implementation to be very useful; components dealing with more general aspects of implementation were also rated as very useful by most but as somewhat useful or not particularly useful by some.

Structured Abstract

Background. Based on an Evidence-based Practice Center (EPC) systematic review, the U.S. Preventive Services Task Force (USPSTF) recommended that clinicians screen adults aged 18 years or older for unhealthy alcohol use and provide counseling for persons engaged in risky drinking. Relying on the EPC review, we implemented an evidence-based, systematic approach to screening and counseling in a General Internal Medicine (GIM) Clinic beginning in July 2016. The approach included Epic electronic health record tools, including visit-based reminders for nurses and providers. In the current methods pilot project, we aimed to (1) further evaluate the implementation and (2) to produce a dissemination package for use by other health systems that describes our implementation and quality improvement process and offers actionable steps to assist other clinics or health care systems wishing to implement similar evidence-based practices.

Methods. We used multiple sources of information to evaluate our implementation and produce a dissemination package (separate document).1 Evaluation of the initial implementation and quality improvement project included collection of data and creation of run charts to track outcome measures for the following: number and percentage of patients screened from the clinic population, fidelity to the screening protocol, and proportion of patients offered counseling for risky drinking, when indicated. Additionally, to assess lessons learned, challenges, and barriers, we conducted semi-structured interviews, guided by the RE-AIM (Reach, Efficacy, Adoption, Implementation, Maintenance) framework, with members of the original implementation project team. Representatives of health systems served as key informants (KIs) to provide an evaluation of the draft dissemination package. Feedback from an online questionnaire completed by the KIs was used to revise the package.

Results. Data collection and tracking for the initial implementation and quality improvement project showed that over 9,000 patients (>70% of eligible patients) were screened over 18 months and 64 percent of patients who had positive initial screens had documented screening-related assessment with the Alcohol Use Disorders Identification Test. Forty percent (141 of 355) were offered counseling for risky drinking when indicated. These results compare very favorably to national rates as fewer than 25 percent of U.S. adults report ever discussing alcohol use with a health professional, fewer than half receive any follow up after identification of unhealthy alcohol use, and fewer than 25 percent of those with significant problems from alcohol use receive a recommendation to stop drinking. Interviews with implementation project team members suggested that EHR tools facilitated provision of the service but might contribute to alert fatigue. Other facilitators included clinic leadership support; a culture of innovation and continuous QI; a strong multidisciplinary team; and, an organized plan for training faculty and residents. Clinic and visit factors such as competing demands, a large patient population, and turnover in nursing staff and resident providers were identified as potential barriers. The dissemination package contains components corresponding to the most important aspects of the implementation process, with descriptions specific to screening and counseling for unhealthy alcohol use (including resources such as screening instruments, and patient and provider materials to support counseling) as well as more general guidance for implementing evidence-based services in primary care. Six KIs completed the package review and evaluation; most (10/12) of the product sections were rated as very useful by a majority of the KIs. Specifically, all KIs found components of the package that provided direct and practical guidance for implementation to be very useful; components dealing with more general aspects of implementation were also rated as very useful by most but were considered somewhat useful or not particularly useful by some. Suggestions for improvement focused on issues of clarity and organization, as well as making the package less Epic-specific to allow for broader applicability.

Conclusions. Evidence-based screening and counseling for unhealthy alcohol use can be successfully implemented with electronic health record tools; our initial quality improvement project, which benefited from dedicated funding and a multi-disciplinary team, resulted in screening and counseling rates greater than those reported in national data. A dissemination package describing the process, barriers, and facilitators was viewed favorably by KIs. Similar dissemination packages could be developed for other EPC reports, but to be feasible additions to the scope of work would require expansion of the timeline and resources as well as input from recent implementation of the evidence-based service.

Reference

  1. Barclay C, Viswanathan M, Ratner SP, et al. Implementing Evidence-based Screening and Counseling for Unhealthy Alcohol Use with Epic-based Electronic Health Record Tools: A Guide for Clinics and Health Systems, Developed as Part of a Pilot Dissemination Project (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No.290-2015-00011-I.) AHRQ Publication No. 18-EHC020-1-EF. Rockville, MD: Agency for Healthcare Research and Quality; September 2018. DOI: https://doi.org/10.23970/AHRQEPCMETHENGAGEALCOHOLGUIDE. Posted final reports are located on the Effective Health Care Program search page.

Citations 

Methods Report

Suggested citation: Barclay C, Viswanathan M, Jonas DE. Development of a Primary Care Guide for Implementing Evidence-based Screening and Counseling for Unhealthy Alcohol Use with Epic-based Electronic Health Record Tools: A Pilot Dissemination Project. Methods Research Report. (Prepared by RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2015-00011-I). AHRQ Publication No. 18-EHC020-EF. Rockville, MD: Agency for Healthcare Research and Quality; September 2018. Posted final reports are located on the Effective Health Care Program search page. DOI: https://doi.org/10.23970/AHRQEPCMETHENGAGEALCOHOL.

Implementation Package

Suggested citation: Barclay C, Viswanathan M, Ratner S, Tompkins J, Jonas DE. Implementing Evidence-based Screening and Counseling for Unhealthy Alcohol Use with Epic-based Electronic Health Record Tools: A Guide for Clinics and Health Systems, Developed as Part of a Pilot Dissemination Project (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No.290-2015-00011-I.) AHRQ Publication No. 18-EHC020-1-EF. Rockville, MD: Agency for Healthcare Research and Quality; September 2018. Posted final reports are located on the Effective Health Care Program search page. DOI: https://doi.org/10.23970/AHRQEPCMETHENGAGEALCOHOLGUIDE.