Narrowing the Research-Practice Divide in

1. Narrowing the Research-Practice Divide in Evidence-Based Medicine with Adoption of Electronic Health Record Systems Challenges Balancing the Needs of Diverse Stakeholders in Community-based Addiction Treatment Carla A. Green, PhD, MPH Center for Health Research, Kaiser Permanente Northwest July 13-14 2009

2. Overview • Over the last two days, we’ve heard about the promise of EHRs, and the need to use them: • To improve care quality, reduce costs, and integrate care • To provide clinical decision support and aid guideline implementation • To provide population- and panel-based care • To monitor outcomes and foster clinical and population-based research, including biosurveillance & adverse events reporting • To aid in billing, reimbursement and other administrative processes

3. Overview • And, we’ve heard about barriers to implementing and using EHRs, including: • The complexities of systems • Regulatory & privacy concerns and constraints, including who can see what • Requirements for data transfer and sharing, like HIPAA • The need for and challenges of interoperability • Problems with source data and data from multiple sources • Challenges using EHR-based data for medical and behavioral research • Challenges in implementing EHRs in addiction treatment settings

4. Overview • We’ve also seen examples of: • The benefits of implementation for clinicians, administrators, and researchers • Settings where implementation has succeeded • Lessons learned in implementing and using EHRs and EHR-based data • The advantages of working out ways to share data across systems • For clinical care • For research

5. Next steps: • Yet, the burning question is: How do we implement and use EHRs in community-based addiction treatment settings? • Implementation needs to be widespread to achieve the promise of EHRs • BUT, most systems have been developed for medical settings, and community treatment agencies are far more diverse • We must find ways to develop, implement, and publicize and foster adoption of systems that: • Work in these diverse settings • Remain interoperable

6. Challenges in design and implementation: • The treatment workforce differs from that in medical settings • Staff range from those in recovery without professional training to individuals with advanced degrees in medicine and psychology • Treatment settings vary widely in approach, goals and size: • From inpatient detox, to intensive drug-free outpatient care, to residential treatment, therapeutic communities and office-based opiate replacement therapy • Some approaches to substance abuse treatment may be less amendable to guideline-based care than medical practices • Treatment often includes a broader range of care, including self-help, than is typically managed in EHRs

7. There are also important differences in readiness for, and acceptance of, EHRs: • Agencies and staff vary greatly in their IT sophistication and computer literacy • Using data, quality and process improvement, and outcomes assessment remain foreign to many agencies and staff • For example, some agencies don’t yet have decent telephone systems • Agencies are often strapped for funds, limiting ability to spend on IT infrastructure, initial training, maintenance and user support • Even if funds can be found to add EHRs, providing funding for long-term IT support may not be feasible with current funding streams • High rates of staff turnover increase training costs substantially

8. So, what to do? • First, collaborate with stakeholders • Talk with treatment program administrators and clinicians, and front-line staff • Learn about how they view EHR systems, data, and data management • Identify commonly perceived barriers to new systems • Learn what clinicians and administrators need to help them do their daily work • Identify gaps in clinical care and problem business and administrative processes • Talk with researchers, learn what they need to carry out reasonable projects

9. Then, collaborate on assessment of existing systems, modifications, or designs: • Work with stakeholders to identify methods that are responsive to identified barriers and needs • Determine if existing EHR systems can address problems • Develop a “community of use” (such as NIATx has done for process improvement) • Try to clarify and address privacy requirements that might impede implementation and interoperability • Design or choose systems and implementation methods that will facilitate agency and staff buy-in • Find, distribute, and make affordable existing EHR systems and implementation approaches • Provide incentives and requirements, at the state and federal level, that push agencies toward adoption and implementation

10. So, how do we do this and what do we already know? • Results from an exploratory project of data management practices that grew out of NIATx: • In-depth, exploratory, qualitative study of data management capacity in eight US substance abuse treatment agencies • Selected to represent a range of size, location, and IT sophistication Wisdom JP, Ford,JH, Wise M, Mackey D, and Green CA. (under review). Substance Abuse Treatment Programs’ Data Management Capacity: An Exploratory Study. Journal of Behavioral Health Services & Research

11. Challenges in Data Collection, Storage & Use • Less-sophisticated systems (4 of 8): • Were sometimes still completely paper-based • Collected information on paper, then entered it into unlinked databases • Had limited or no integration across multiple sources of data • More sophisticated systems allowed direct entry through electronic systems that were linked • Only two programs used aggregated data to make program-related decisions

12. Findings: Data-related Challenges (continued) • Only half of the programs had either full or partial integration of electronic systems (e.g., linked IT capacity across billing and client data, levels of care & program locations) • Headquarters & administrative sites were more likely to have clinical electronic data systems • Satellite sites, particularly in rural areas, were less likely to have such systems • Levels of care at the beginning and end of the treatment continuum (e.g., medical detox, transitional housing) were more likely to use paper-based systems • Of particular relevance for researchers, none of the agencies reported concerns about, or procedures for, ensuring data reliability or validity

13. Challenges: Funding Systems & Support • Funding was seen as the primary barrier to improving data systems • Concerns included up-front costs for hardware, software, training, and transitions • Ongoing operational costs for new systems • Inability to give up reimbursable staff time for researching, learning and implementing new systems • Poor current infrastructure, including slow internet access and computers, that would have to be addressed or replaced

14. Challenges: Software Availability and Appropriateness • Two directors indicated that they were unable to find data management systems that balanced price, flexibility, comprehensiveness, integration, and efficiency • Systems were seen as too complex (like those for hospital systems) or too simple (like basic practice management software) • Small agencies had particular difficulties in finding and funding appropriate software

15. Findings: Staff-related challenges • Some staff needed basic computer training (using Windows, opening and saving documents) • Workflow changed with electronic systems • Some staff were concerned about focusing on technology rather than client needs • Clinicians worried that focusing on computer screens during intakes would interfere with developing rapport with clients • Some staff were concerned that new IT systems fostered collection of data that were not used at all, or not used for clients’ benefit

16. Findings: Opportunities • Various practices were labor intensive so could be used to enhance the business case for EHRs • Double data-entry and multiple storage systems were common across the eight programs • Replacing such systems could provide funds and FTE that could be directed toward new systems • All programs, even the most sophisticated, used paper to create client charts or “binders” • Treatment progress notes and summary reports were often created with word processing software, stored separately, and then printed for charts

17. Opportunities (continued) • Integrated systems enhanced productivity, improved communication, and increased attention to data that could be used for decision making • After integrated systems were implemented, staff time was reduced for completing routine tasks, particularly billing and other large-volume processes • Easy access to client data, insurance verification, and group treatment notes reduced clinician time and allowed for more direct client interaction • Treatment plans were more readily available and there were fewer communication breakdowns during transitions in care

18. Other Opportunities (continued) • Some agencies had no legacy systems to deal with • Such agencies lacked infrastructure • But transitions to new systems should be simpler

19. Facilitators of Better Systems • Strong leadership supported improved data management • Creative problem-solvers overcame barriers to better systems • Leaders who valued data-based decision making were willing to make difficult resource allocations to enhance IT infrastructure

20. Facilitators (continued) • IT sophistication among state authorities appeared to foster IT development among agencies • The more sophisticated agencies were located in states that provided 2 or more of the following: • All-electronic reporting systems • Feedback of program-level aggregated data as an incentive • Intermediate and advanced training on data management and interpretation • State requirements and support for improved infrastructure also facilitated adoption of new IT systems

21. Next Steps: Summary • Assess the needs of substance abuse treatment agencies in the context of EHRs • Work to change the culture in these agencies to support adopting EHRs • Consider NIATx-like approaches • Educate leaders about advantages and availability of EHRs for substance abuse treatment agencies • Modify EHRs as needed to meet agency needs • Push states to adopt practices and requirements that facilitate uptake of EHR systems

22. Thank you!