Are EHRs holding back alcohol-related care?

A study published in December 2024 in the Journal of the American Medical Informatics Association (JAMIA) Open determined that most electronic health records (EHRs) used in primary care settings lack the necessary tools to support evidence-based alcohol-related care. Researchers identify this shortcoming as a critical gap in addressing a leading preventable cause of death in the United States, responsible for 178,000 deaths each year.

The researchers, led by Katharine Bradley, MD, MPH, James McCormack, PhD, and Megan Addis, BA, assessed the functionalities of 21 EHRs used by 167 primary care practices across seven U.S. states—Illinois, Indiana, Michigan, North Carolina, Oregon, Virginia and Wisconsin—focusing on their ability to effectively facilitate care for patients with alcohol use disorders (AUDs) and support evidence-based interventions.

As a result of the study, researchers determined that only one of ten basic EHR functions required to support evidence-based alcohol-related prevention and only two of eleven basic functions for AUD treatment were present in more than half of the EHR systems evaluated. Moreover, few EHRs could generate reports for national performance measures related to alcohol screening and brief intervention (14%) or AUD treatment (5%).

“These gaps in EHR support for alcohol-related primary care are alarming giving that alcohol screening and brief intervention is ranked second among all [U.S. Preventive Services Task Force (USPSTF)] recommendations for adult primary care in terms of clinical burden prevented and cost effectiveness, and the quality of care for AUD has been shown to be poorer than for any other chronic condition, with no improvement over the past 20 years,” the authors of the study wrote.

Shortcomings in EHR functionality

Although researchers emphasize that performance measurement is the “cornerstone of quality improvement,” the study demonstrates that EHR support for alcohol-related care is significantly behind support for other chronic conditions.

Consistent with the noted EHR deficits, when evaluating gaps in basic EHR functions across the study’s primary care practices, they found that, regarding prevention, 62% of the analyzed EHRs included a validated screening questionnaire, 46% automatically scored the screening instrument, 62% could report the percent screened, 37% could report the percent screening positive and just 7% could report the percent offered brief intervention.

For alcohol treatment, 49% of primary care practices’ EHRs were able to report the percent diagnosed with AUD, 58% allowed documentation of referral, 91% allowed documentation of treatment with AUD medication and only 3% of practices could report the percent of patients who were diagnosed with AUD and received treatment.

These deficits are compounded by issues including inflexible and difficult-to-use features that limit the potential for iterative quality improvement. For instance, some systems only produce annual aggregate reports, making it challenging for practices to track progress or effectively address shortcomings.

Performance measurement and quality improvement

Performance measurement is the cornerstone of quality improvement, yet the study highlights that EHR support for alcohol-related care significantly lags behind other chronic conditions, including hypertension and diabetes.

Although EHRs for these conditions commonly include tools for clinical decision support and population health management, similar capabilities for alcohol-related care are scarce, despite USPSTF recommendations. Researchers emphasize that EHR support is critical for improving patient health outcomes regarding alcohol-related care, and suggest that necessary features for evidence-based alcohol-related care be included as core EHR components for primary care practices at no additional cost.

To achieve these goals, the study workgroup outlined several recommendations for EHR vendors:

• Flexible screening tools: EHRs should include validated alcohol screening questionaries with automatic scoring, allowing practices to customize screening frequency and delivery methods (i.e., online patient portals). They should also provide links to evidence-based guidelines for interventions and treatments.
• User-friendly clinical tools: Prompts and reports should be easy to access and use. Automatic alerts should guide providers through the care process, from screening to follow-up interventions, with prompts turning off automatically once actions are documented.
• Comprehensive data capture: Key elements of alcohol-related care, including screening results, brief interventions, referrals and treatments, should be captured as discrete data, enabling better monitoring of patient outcomes and care effectiveness over time.
• Streamlined reporting: EHRs should allow practices to generate reports on performance measures easily and frequently. The ability to analyze individual steps in the care workflow—screening, positive screens and treatment engagement—is essential for iterative quality improvement.

According to the researchers, although EHRs have revolutionized patient care in a plethora of ways, their limitations in supporting alcohol-related care highlight a broader issue of misalignment between EHR design and clinical priorities.

“Clinicians and staff in primary care must have access to tools that can provide needed prompts, incorporate evidence-based clinical decision support and improve the quality of documentation and performance reporting for alcohol screening, prevention and treatment,” the authors of the study concluded. “Change will require EHR vendors to add the basic functionality needed for alcohol-related care.”