Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD 20892-9557, USA.
Addiction. 2013 Jan;108(1):3-8. doi: 10.1111/j.1360-0443.2012.03876.x. Epub 2012 May 8.
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.
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.
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.
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.
电子健康记录（EHRs）对于提高医疗保健质量和效率至关重要。到 2015 年，美国医疗保险和医疗补助服务中心（CMS）的医疗服务接受者必须展示对 EHRs 的“有意义的使用”。在当前的美国医疗保健环境中，物质使用障碍（SUD）的检测和治疗严重不足。因此，迫切需要改善医疗环境中 SUD 的识别和临床干预。国家药物滥用研究所临床试验网络（NIDA CTN）利用其基础设施和专业知识，将相关利益攸关方聚集在一起，就一般医疗环境中的 SUD 简短筛查和初步评估工具达成共识，目的是将其纳入美国 EHRs。
确定利益攸关方，并就一般医疗环境中 SUD 的经过验证的筛查和评估工具征求意见并达成共识，以制定共同的数据元素，作为 EHRs 用于筛查、简短干预和转介治疗（SBIRT）的共享资源，旨在支持发展中的全国卫生信息网络中的互操作性和数据交换。
通过利益攸关方的一致意见，选择了经过验证的筛查和简短评估工具，并辅以临床决策支持工具，用于门诊一般医疗环境。
创建和采用一套经过验证的核心通用数据元素，并将此类基于共识的数据元素纳入一般医疗环境，将使 SUD 治疗能够融入主流医疗保健，并支持采用和“有意义的使用”美国国家协调员办公室（ONC）认证的 EHRs，以及 CMS 报销。
