I am Thomas McLellan, a researcher in the substance abuse treatment field from the University of Pennsylvania and the Treatment Research Institute
I am not an advocate and neither I nor my Institute represents any treatment or government organization
I offer evidence on issues and standards related to the inclusion of alcohol and drug abuse and treatment into the developing electronic health record (EHR). By “treatment” here I mean the full range of activities from screening and laboratory testing, through diagnoses and brief interventions within primary and general medical settings – to referral and specialty addiction treatment.
The testimony is based on my own work of over 400 studies published in scientific journals – and based on several reviews of the scientific literature by colleagues and other research organizations.
My testimony contains only four points
1 – Information about substance use and substance abuse treatment should be part of the EHR. There are two major reasons for this – both relating to quality and safety of care delivery. First – alcohol and other drug addiction are among the most prominent and prevalent healthcare conditions. Addiction affects more than 20 million people annually and more than 2 million people receive specialty care – an unknown but substantially larger number of people receive unrecorded addiction related care from primary care physicians. Treatment response rates and relapse rates are quite similar to those seen in other chronic illnesses such as diabetes, hypertension and asthma. Moreover, new medications for the treatment of all forms of addiction are entering primary care practice (three in the past three years). Thus it is likely that even more of those affected will receive treatment and in turn, this information must become part of the health record.
Second, knowledge about alcohol and other drug use is essential for the safe, effective and efficient management of many chronic illnesses such as hypertension, diabetes, breast cancer, sleep disorders, and chronic pain. Systematic reviews of alcohol and drug effects on these conditions now show significant variability in the course, costs and results of care of these diseases due to the presence of even sub-diagnostic levels of alcohol or drug use.
Summary – It is not possible to provide safe or effective healthcare without accurate information about history and current status of substance use. Physicians and healthcare professionals need to know about substance use issues for the safe and effective management of addiction and of many other mainstream diseases.
2 – Addiction treatment has changed in concept and delivery over the past 10 years and it has significant implications for healthcare monitoring.
Addiction used to be considered a bad habit best treated through insight oriented therapy in an inpatient setting. Now addiction is considered like other chronic illnesses (evidence available if necessary) and today over 90% of addiction treatments are provided in outpatient settings for unspecified periods of time.
Consequently, the clinical monitoring approaches used in the treatment of other chronic illnesses are also appropriate in the treatment of addiction. These approaches stress patient responsibility for disease and lifestyle management and the early detection of relapse. These contemporary clinical approaches require modern information management techniques and systems that provide standardized, relevant monitoring information to the clinician and to the payers.
3 – The values and principles associated with “patient centered care” (Crossing the Quality Chasm, NAS – IOM, 2001) in general medical settings also apply in the treatment of substance abuse and addiction. That is:
a – All health information ultimately belongs to the patient. Patients should decide on what, how and to whom information can be transmitted.
b – Except in the most extreme (and usually temporary) cases – substance abusing patients are also able to make these information sharing decisions.
Summary – For too long, policy makers, insurers and providers have used diagnostic and legal distinctions to separate substance abusing patients and substance abuse treatments from mainstream health. Issues of substance abuse are sensitive but no more so than venereal disease, Alzheimer’s disease and depression. Substance abusing patients can and should be responsible for the decisions concerning the sharing of their information. An effective EHR should make provision for the safe handling of all sensitive healthcare information – including substance abuse information.
4 – Integrating substance abuse information into mainstream healthcare and into the EHR requires two areas of infrastructure development:
a – Mainstream healthcare needs to use computer codes to describe the diagnoses and empirically supported medications, therapies and interventions used in the treatment of substance use disorders. Most of these codes exist now but have not been widely used or well disseminated outside substance abuse specialty care settings. This common set of codes will facilitate the use and improve the accuracy of healthcare information.
It should be noted that the failure of widespread use of these codes is not coincidence. Insurers and managed care organizations have been able to restrict physician participation by purposely failing to provide these codes. Quite simply, if a type of medication or care cannot be ordered by code within a clinical information system – it cannot be paid for. Thus, it is likely that there will be resistance to this suggestion based a wish to preserve profits veiled in a concern for patient confidentiality.
b – The US addiction treatment system has a broad and immediate need for resources to improve information infrastructure. Currently, less than 40% of addiction treatment programs have information systems available for clinical decision support and clinical record keeping. This infrastructure problem is due in some part to chronically poor funding levels but even more to the fact that so many of these programs are not connected professionally, financially or clinically with the rest of mainstream healthcare.
For the reasons stated at the outset – substance abuse issues are integral to mainstream healthcare. Managing contemporary addiction treatment requires the same kind of information system now used in managing other prevalent, chronic illnesses. Managing most chronic illnesses requires timely, accurate information about alcohol and other substance use. Integrating substance abuse information into mainstream EHR is as important and as feasible as integrating information about Alzheimer’s, depression, venereal disease and other “sensitive” diseases. The creation and development of a truly integrated HER – one which includes pertinent alcohol and drug abuse information – provides an important opportunity to improve the effectiveness and safety of mainstream healthcare. It is not safe, efficient or effective to operate as though addiction does not matter in healthcare