Common data elements for substance use disorders in electronic health records: the NIDA Clinical Trials Network experience.
Summary of "Common data elements for substance use disorders in electronic health records: the NIDA Clinical Trials Network experience."
Aimsâ Electronic health records (EHRs) 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. Methodsâ 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. Resultsâ 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 general medical settings. Conclusionsâ 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.
Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD, USA The EMMES Corporation, Rockville, MD, USA.
This article was published in the following journal.
Name: Addiction (Abingdon, England)
- PubMed Source: http://www.ncbi.nlm.nih.gov/pubmed/22563741
- DOI: http://dx.doi.org/10.1111/j.1360-0443.2012.03876.x
Medical and Biotech [MESH] Definitions
Systematic gathering of data for a particular purpose from various sources, including questionnaires, interviews, observation, existing records, and electronic devices. The process is usually preliminary to statistical analysis of the data.
Electronic Health Records
Media that facilitate transportability of pertinent information concerning patient's illness across varied providers and geographic locations. Some versions include direct linkages to online consumer health information that is relevant to the health conditions and treatments related to a specific patient.
Health Records, Personal
Longitudinal patient-maintained records of individual health history and tools that allow individual control of access.
Compilations of data on hospital activities and programs; excludes patient medical records.
Patient Access To Records
The freedom of patients to review their own medical, genetic, or other health-related records.
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