Integrating Technology into Substance Use Treatment and Health Care:
New Opportunities for Providers and Patients
Stacy Sterling
Division of Research, Kaiser Permanente
National Behavioral Health Information Management Conference & Exposition
April 16, 2015
The Affordable Care Act creates opportunities
and challenges for AOD services in health care
 Will increase services for alcohol and drug problems
– One of 10 “Essential Health Benefits”
– Behavioral Services
 Many formerly uninsured receiving insurance
– Alcohol problems over-represented in the newly insured population
 Sea-change in many facets of service delivery
– Spectrum of problems: risk behaviors and primary disorders
– Range of settings: emphasis on primary care
 Accountability: Performance measures
– E.g., HEDIS Substance Abuse Treatment Initiation and Engagement,
Integration with mainstream health care

Huge opportunities for integrating AOD services in health care
– Health Reform (Affordable Care Act - ACA)
– The Mental Health Parity and Addiction Equity Act

Affordable Care Act advancing health technology for clinical care
– By 2016: EHRs reporting of clinical quality measures, electronic
transmission of treatment plans, clinical decision support; patient portals
– In many contexts: Health Plans, FQHCs, IHS
– Our field comes to this late – but we are catching up

Primary Care as a health home
– The three pieces: screening, treatment, monitoring
– Self-management & Patient Activation
Past
Future
Mainly Ignored in primary care
Screened & monitored in primary care
Focus on dependence
Full spectrum of problems
Paper charts: little contact
between specialty AOD &
health care
EHR (“meaningful use”) clinical
coordination, patient portals, health IT
Tx options, meaningful use penalties
Episodic specialty treatment
Ongoing care management
Little focus on health issues
Relationship with medical problems
“Prescribed” Tx programs
Multiple & patient-centered Tx options
Medications seldom available
Medications available
Little accountability
Performance measurement, outcomes
12-step
12-step + social network innovations
Integrated health
care delivery
system
(medical,
psychiatry &
AOD services)
3.6 + million
members,
diversity
increasing with
ACA)
Patient portal,
clinical
guidelines
Integration with Primary Care as the Anchor
(Health Home)
Screen and treat in PC
(if moderate problem,
continue monitoring)
Specialty care if needed
Primary
Care
Specialty
Care
Back to Primary Care for
monitoring
Bodenheimer T, Wagner E, Grumback K. Improving primary care for patients with chronic illness. JAMA .2002; 288:1775-1779.
Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner E. Collaborative management of chronic illness. Ann Intern Med. 1997;
127(12):1097-1102.
Chi FW, Parthasarathy S, Mertens JR, Weisner C. (2011) Continuing care and long-term substance use outcomes in managed
care: initial evidence for a primary care based model. Psychiatr Serv. 2011;62(10):1194–1200.
Parthasarathy S, Chi FW, Mertens JR, Weisner C. (2012) The role of continuing care on 9-year cost trajectories of patients with
intakes into an outpatient alcohol and drug treatment program. Med Care. 2012;50(6):540–546.
INNOVATIONS FOR PROVIDERS
How do clinicians use them?
 Screening
 Checking guidelines
 Decision support
 Checking for co-occurring problems/medications
 Checking for treatment history
 Retrieval of progress notes
 Easily seeing information from other departments
 Rapid queries (to examine “across” patients)
 Communicating with patients (encrypted email)
Electronic health record and registries:
Clinical implications
What is a registry?
 Continually refreshed database on a group of people meeting
certain criteria
 Provides up-to-date information (e.g. clinical characteristics,
health care utilization, medication use)
Registry Development
Health
System/Clinical
Encounters
EHR
Registries
How Can Registries Be Used?
 Can identify high risk patients according to various criteria
 Track outcomes of interest over time
– Long term use
– Poisoning/overdose, abuse/dependence, ER use
 Examine comorbidities
• Correlation with other health outcomes with access to the whole medical record,
other registries
 Can target certain populations for disease management
– Cancer Registry, HIV Registry, Diabetes, Preventing Heart Attack and Stroke
Registry (PHASE)
 Can identify providers of these patients for interventions
 Collaborating with other health systems to create networks
– Potential for surveillance for some substances
– Common Data Elements
Alcohol as a Vital Sign (AVS):
Alcohol SBIRT in Adult Primary Care
Best Practice Alert
After Visit Summary
Tips for Cutting Down on Drinking
Cutting back on drinking can lower your risk for many health problems, including diabetes, high blood pressure, depression and falls. Small
changes can make a big difference. Depending on your health status, I may advise you to drink less or abstain.
To help you to stay healthy and reduce alcohol consumption, I recommend that you try 2 or 3 of the tips below. If one doesn't work, try
something else.
Keep track
Find a method of tracking that works for you, such as on your smart phone, keeping a note card in your wallet, or checking off days on a
calendar. If you keep track of each drink before you drink it, this will help you slow down. You can also recruit a supportive friend or family
member to help monitor your progress.
Count and measure
Know the standard drink sizes so you can count your drinks accurately. A standard drink is 12 ounces of regular beer, 8 to 9 ounces of malt
liquor, 5 ounces of table wine, or 1.5 ounces of 80-proof spirits. Measure drinks at home. Away from home, especially with mixed drinks, it
can be hard to keep track. You may be getting more alcohol than you realize. With wine, ask the server not to “top off” a partly filled glass.
Set goals
Decide how many days a week you want to drink and how many drinks you’ll have on those days. It’s a good idea to have some days when
you don’t drink at all. Drink within these limits:
For healthy men up to age 65
• No more than 14 drinks in a week, AND
• Never more than 4 drinks in any one day
For healthy women of any age (and healthy men over age 65)
• No more than 7 drinks in a week, AND
• Never more than 3 drinks in any one day
Pace and space
Sip your drink slowly and set your glass down between sips. Have no more than one alcoholic drink per hour. Alternate “drink spacers” such
as a full glass of water (8 ounces) between drinks.
Include food
Don’t drink on an empty stomach. Enjoy some healthy food so the alcohol will be absorbed more slowly into your system.
Avoid “triggers”
What triggers your urge to drink? If certain people or places make you feel like drinking even when you don’t want to, try to avoid them. If
certain activities, times of day, or feelings trigger the urge, plan what you’ll do instead of drinking. If drinking at home is a problem, don’t
keep alcohol there.
TEEN SBIRT
SUBSTANCE USE SBIRT IN PEDIATRIC
PRIMARY CARE
Full CRAFFT Questionnaire added to EMR – Assessment and 1-year Outcomes
Patient Baseline and Outcomes Questions in EMR (flowchart shows over time)
Patients’ progress over time can be viewed in this CRAFFT flowsheet
Care Management
Screenshot of e-Letter
Treat and retest
Limites Maximos Potable
Para hombres 65 y más joven, no más de 4 bebidas por día y no más de 14 bebidas por semana
Para mujeres, y para los hombres más de 65 años de edad, no más de 3 bebidas por día y no más de 7 bebidas por
semana
12 onz. de
Cerveza
12 onz.
8-9 onz.
Licor de
Malta
8.5 onz.
5 onz.
Vino
de Mesa
5 onz.
3-4 onz.
Vino
alcoholizado
3.5 onz.
2-3 onz. de
Cordial,
Licor,
Licor
Aperitivo
2.5 onz.
1.5 onz. de
Brandy
1.5 onz. de
Licor Fuerte
(80-graduacion
alcoholica)
tequila, vodka,
whiskey, etc
1.5 onz.
1.5 onz.
12 onzas de Cerveza= una bebida, 16 onzas = 1.3 bebida, 22 onzas = 2 bebidas, 40 onzas = 3.3 bebidas
12 onzas Licor de Malta = 1.5 bebida, 16 onzas = 2 bebidas, 22 onzas = 2.5 bebidas, 40 onzas = 4.5 bebidas
750 mL botella de Vino (25 onzas) = 5 bebidas
Licor Fuerte de 80 graduacion: (16 onzas.) = 11 bebidas, un quinto (25 onzas) = 17 bebidas, a 1.75 L (59 onzas.) = 39 bebidas
Giới hạn tối đa để giữ an toàn khi uống rượu:
Đối với đàn ông cho đến tuổi 65, không quá 4 ly một ngày VÀ không quá 14 ly một tuần
Đối với đàn bà và đàn ông trên 65 tuổi, không quá 3 ly một ngày VÀ không quá 7 ly một
tuần
12oz. bia
hay cooler
8-9oz. rượu
mạch nha
8,5oz. trong một
ly có dung tích
12oz. Do đó,
nếu đầy, nó sẽ
chứa 1,5 ly
chuẩn rượu
mạch nha
5oz. rượu
vang
3-4oz. rượu
vang nồng
độ cồn cao
(ví dụ như rượu
ngọt sherry hay
port) ly trong
hình chứa 3,5oz.
2-3oz. rượu
khai vị,
rượu mùi,
rượu
hương
nước trái
cây
ly trong hình
chứa 2,5oz
1,5oz. rượu
brandy (như
cognac)
(một chung
rượu nhỏ dung
tích 45cc gọi là
jigger)
1,5oz. rượu
mạnh
(một chung
rượu 45 cc –
jigger – của
40% cồn gin,
vodka, whiskey,
v.v.) Trong hình
cho thấy rượu
chưa pha chế
và trong ly gọi
là highball
glass có đá để
cho thấy độ cao
trước khi pha
chế thêm.
Đối với bia: 12 oz. = 1 ly, 16 oz. = 1,3 ly, 22 oz. = 2 ly, 40 oz. = 3,3 ly
Đối với rượu mạch nha: 12 oz = 1,5 ly, 16 oz. = 2 ly, 22 oz. = 2,5 ly, 40 oz. = 4,5 ly
Đối với rượu vang: 1 chai 750 ml (25 oz.) = 5 ly
Đối với rượu mạnh 40%: 1 pint (16 oz.) = 11 ly, 1 fifth (25 oz.) = 17 ly, 1,75 L (59 oz.) = 39 ly
Assessing Readiness to Change
Use Readiness Ruler
 On a scale of 1-10, 10 being very much….
– “How much right now do you want to change your drinking
habits?”
How ready are you?
1
2
3
Not ready
Rollnick et al. 1999
4
5
6
7
8
9
Unsure
10
Ready
34
NEW INNOVATIONS FOR PATIENTS
Examples of using Patient Portal
 Graphing blood pressure/lab tests
 Planning prevention tests
 Preparing for doctor visit/making appointments
 Emailing doctor
 Changing doctors
 Sleep/weight-loss/nutrition/anger management/mindfulness meditation/CBT, etc.
programs
Mobile Apps
We reviewed his lab results which pt found exciting “wow this is so cool, I like that is tells me the normal range to
be in, I should look at this more often.”
"I have gained weight since being in recovery with all my meds. So I signed up for Balance on Kp.org and a
nutrition class so I can improve my diet. I also listen to those podcasts they really help with my insomnia.”
One participant shared that, since last week, she has been listening to 3 KP.org podcasts/day, and that she has
found this to be very helpful in her recovery. She stated, "I never knew how many negative messages were in my
head, and they provide such a positive perspective for my health".
The participant who feared working on the computers due to her dyslexia, tearfully noted that not only did she
overcome challenges that seemed almost impossible to solve (ordering a new password after being locked out of
kp.org), but she practices using kp.org on her own at home which makes her feel empowered and proud.
One participant noted that after class last week, he went home, emailed his new doctor and discussed the skin
condition he has been worried about for years. He said "thank you for kicking my butt to do that, I never would
have emailed her until you showed me how.” Thank you for going through my medical record with me, there were
things I would not have looked for and it was good to review my past test results.
One participant report checking his glucose level improved his mood because it was in normal range and he is at
genetic risk of diabetes
One person reported being prescribed medication, but not having sufficient information regarding pharmacy
locations or the medication itself. After, attending Navigating the System, he now knows how to locate the
pharmacy and plans to take his medication.
RESEARCH TEAM
Principal Investigators
Cynthia Campbell, PhD
Lyndsay Ammon Avila, PhD
Jennifer Mertens, PhD
Derek Satre, PhD
Stacy Sterling, MSW, MPH
Kelly Young-Wolff, PhD
Connie Weisner, DrPH, LCSW
Health Economist
Sujaya Parthasarathy, PhD
Senior Research Administrator
Alison Truman, MHA
Analysts/Biostaticians
Felicia Chi, MPH
Andrea H Kline Simon, MS
Wendy Lu, MPH
Tom Ray, MBA
Jessica Allison, PhD
Interview Supervisor
Research Clinicians
Project Coordinators
Thekla B Ross, PsyD
Ashley Jones, PsyD
Amy Leibowitz, PsyD
Gina Smith Anderson
Agatha Hinman, BA
Kathleen Healy, MFT
Sabrina Wood, BA
Research Associates
Georgina Berrios
Virginia Browning
Melanie Jackson
Diane Lott-Garcia
Irene Kane
Clinical Partners
Anna Wong, PhD
Charles Wibbelsman, MD
David Pating, MD
Barry Levine, MD
Charles Moore, MD, MBA
Don Mordecai, MD
Cosette Taillac, LCSW
Murtuza Ghadiali, MD
Mason Turner, MD
KPNC Members
KPNC Primary Care
KPNC Chemical Dependency Quality Improvement Committee
KPNC Adolescent Medicine Specialists Committee
KPNC Adolescent Chemical Dependency Coordinating Committee
KPNC Oakland Pediatrics Department
KPNC Regional Mental Health and Chemical Dependency
Stacy.a.Sterling@KP.org