Screening patients for alcohol misuse and offering brief interventions (BI) to those who screen positive reduces drinking and is a recognized U.S. prevention priority. The Veterans Health Administration (VA) uses clinical reminders (CR) in the computerized patient record system (CPRS) to prompt and document results of alcohol screening, as well as trigger a subsequent CR for BI for patients with positive alcohol screens. Although screening rates are over 90% and rates of documented BI are increasing, research has suggested that the quality of alcohol screening is variable, and little is known about the quality of BI. While previous studies have identified barriers and facilitators to effective implementation of evidence-based practices with clinical reminders in the VA, no study has identified barriers and facilitators specific to implementing alcohol screening and BI using CRs.
The purpose of this study was to identify facilitators and barriers to effective use of alcohol-related CRs. A secondary purpose was to refine methods in preparation for a national evaluation.
This study was an observational, qualitative study of the way clinicians interact with CRs at 9 outpatient clinics within VA Puget Sound. VA clinicians were recruited and verbally consented. Four researchers took notes as they observed clinicians interacting with CRs. Notes were transcribed and analyzed qualitatively using template analysis based on an a priori coding template that was derived from Greenhalgh's implementation model.
Overall, 58 clinical staff (25 RNs, 26 LPNs, 7 Health Techs) and 21 providers (16 MDs, 5 NPs) caring for 166 patients were observed. Observed staff interacted with 528 CRs, including 74 alcohol screening and 14 BI CRs. Analyses suggest substantial variability in the use of CRs to implement alcohol screening and BI across clinics. While some clinics used the screening CR to facilitate verbal in-person screening, others entered patient responses into the CR after completion of a paper- or laminate-based screen. Although, when positive, the screening CR was designed to trigger a subsequent CR for BI, all clinics used paper encounter forms to alert the provider as the CR technology did not support existing patient/clinic flow. Although the alcohol screening and BI CRs were designed as self-explanatory training tools, neither appeared to train users to detect and manage alcohol misuse. For instance, we observed non-verbatim screening, guessing response options, and offering information that were neither prompted by the CR nor recommended by expert guidelines. Finally, the inflexibility of both CRs seemed to compromise authenticity and patient-centeredness of both screening and BI.
Findings suggest that VA's CRs appear to be a useful prompt for alcohol screening and BI but have important limitations as a method of facilitating valid and effective alcohol screening and BI. Several effective strategies to use of CRs were identified and are being shared with local and national VA operational partners.
- Williams EC, Achtmeyer CE, Thomas RM, Grossbard JR, Lapham GT, Johnson-Chavez M, Ludman E, Berger D, Bradley KA. Implementing Alcohol Screening and Brief Intervention with Clinical Reminders: Barriers and Facilitators. Presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 18; National Harbor, MD.
- Williams EC. Implementation of Screening and Brief Intervention. Presented at: American Psychiatric Association Annual Meeting; 2012 May 19; Philadelphia, PA.
- Williams EC, Achtmeyer CE, Thomas RM, Grossbard JR, Lapham GT, Johnson M, Ludman E, Berger DB, Bradley KA. Limitations to Implementing Alcohol Screening with an Electronic Clinical Reminder in the Veterans Affairs Healthcare System: A Qualitative Study. Paper presented at: International Network on Brief Interventions for Alcohol Problems Annual Conference; 2011 Sep 21; Boston, MA.
- Williams EC, Achtmeyer CE, Grossbard JR, Lapham GT, Thomas RM, Johnson M, Bradley KA. Barriers and facilitators to implementing alcohol screening with a clinical reminder in the VA: A qualitative study. Poster session presented at: Research Society on Alcoholism Annual Scientific Meeting; 2011 Jun 28; Atlanta, GA.
- Williams EC, Achtmeyer CE, Grossbard JR, Lapham GT, Thomas RM, Johnson M, Bradley KA. Lessons learned from implementing alcohol screening with a clinical reminder in the Veterans Health Administration: A qualitative study. Poster session presented at: University of Washington Department of Health Services Annual Research Meeting; 2011 Jun 15; Seattle, WA.
Substance Abuse and Addiction
Treatment - Observational, Prognosis
Alcohol, Implementation, Informatics, QUERI Implementation