Use of Electronic Health Information Technology in a National Sample of Hospitals that Provide Specialty Substance Use Care

Abstract

Objective:

Most US acute care hospitals have adopted basic electronic health record (EHR) functionality and health information exchange (HIE) (84% and 88% respectively); there is reason to believe that hospital-based substance use disorder programs may lag behind in their adoption.

Methods:

This study analyzed the 2017 National Survey on Substance Abuse Treatment Services among hospital-based substance use disorder treatment programs to examine: 1) adopted basic EHR functionality (i.e., assessment, progress monitoring, discharge, labs, and prescription dispensing); or, 2) used HIE. Analyses used weighted multivariate models of the EHR and HIE outcomes, adjusted for non-response.

Results:

About two-thirds (67.8% of N = 894) of hospital-based substance use disorder programs reported using basic EHR functionality. Psychiatric hospitals were less likely to adopt than acute care hospitals (OR = 0.5; 95% CI=0.3–0.7), as were for-profit (OR = 0.2; 95% CI = 0.2–0.4) and government-owned hospitals (OR = 0.5; 95% = 0.3–0.8), compared to nonprofits. Hospital programs providing medications for alcohol or opioid use disorders were more likely to use basic EHR functionality (OR = 1.9; 95% CI = 1.3–2.9). Nearly three-quarters (71.28% of N = 839) of hospitals reported using electronic HIE, with basic EHR adoption (OR = 4.7; 95% CI = 3.3–6.8) as the strongest predictor.

Conclusions:

Hospital-based substance use disorder programs trail behind U.S. acute care hospitals in their adoption of basic EHRs and electronic HIE. These findings raise concerns about missed opportunities to improve hospital-based substance use disorder care quality and safety, as well as performance measurement.

Introduction

Substance use disorders cause significant morbidity and mortality.¹ Individuals receiving specialty substance use disorder care in hospital settings are often among those with the most severe conditions and associated health complications. Further, the risk of drug interactions between alcohol/drugs and prescribed medications^2–4—including increased risk of death⁵ – is considerable; these safety risks are heightened when medications used to treat substance use disorder are not in the medical record.⁶ Indeed, managing these risks requires not only accurate documentation in the health record, but also robust health care coordination and communication among providers caring for patients within the hospital and with post-discharge care providers.

Electronic health records (EHRs) offer opportunities to improve the quality and safety of healthcare. They have been demonstrated to significantly reduce medication errors and adverse drug events, improve guideline adherence, and facilitate patient communication.^7–11 Recent evidence also finds they are associated with reduced hospital mortality.¹² Additionally, use of electronic health information exchange (HIE) has been associated with improved healthcare quality, safety, and reductions in unnecessary utilization and costs,¹³ and facilitates timely information exchange to providers at the next level of care. As of 2015, 84% of acute care hospitals had adopted at least basic EHR functionality in at least one unit of a hospital.¹⁴ As of 2017, 88% of acute care hospitals electronically send HIE to providers at the next level of care.¹⁵ Recognizing the importance of HIE for the quality and safety of healthcare, the 21^st Century Cures Act requires the Office of the National Coordinator (ONC) for Health Information Technology to promulgate regulations to further support the exchange of health information; in May of 2020, the ONC published its Final Rule to advance this goal.¹⁶

However, use of basic EHR functionality and electronic HIE from hospital-based specialty substance-use programs may be lower than the national estimates of EHR adoption/HIE in acute care hospitals. One reason may be because specialty substance use disorder providers are subject to a federal health privacy law (42 Code of Federal Regulations [CFR] Part 2) that is considerably stricter than the Health Insurance Portability and Accountability Act (HIPAA), and EHRs have limited ability to manage these additional privacy requirements. Further, Part 2-covered programs may be disproportionately located in psychiatric hospitals—hospitals identified as having much lower basic EHR adoption rates.¹⁴

EHR adoption at acute care hospitals, specifically at least basic EHR functionality adoption, and electronic HIE are derived from hospital responses to the American Hospital Association Annual Survey Information Technology (IT) Supplement. The functional features which constitute basic EHR adoption was determined by expert consensus,¹⁷ are considered the standard definition of basic adoption,^18–21 and have been used by the ONC in their national estimates.^14,22 The IT Supplement also provides the ONC with national estimates of hospital-based electronic HIE. However, it cannot provide estimates for specific programs within hospitals because it asks hospital respondents to report on adoption “in at least one unit” of the hospital. Thus, for programs within hospitals that are subject to additional federal privacy requirements (such as substance use disorder specialty programs), EHR adoption or HIE in these programs may not match the EHR adoption/HIE at the hospital overall.

The aim of this study is to estimate the use of basic EHR technology and electronic HIE using the Substance Abuse and Mental Health Administration’s (SAMHSA) National Survey of Substance Abuse Treatment Services (N-SSATS) survey and determine hospital characteristics that predict use of EHR technology and electronic HIE within these settings. We hypothesize that the rate of basic EHR functionality adoption and electronic HIE use in these programs will be lower than national estimates for hospitals overall.

Methods

Data Source

The N-SSATS is an annual census of all specialty providers of substance use treatment services in the United States. It is administered to specialty providers at all levels of care (e.g., inpatient, residential, partial hospital, outpatient) and in the case of hospitals, among acute care/general hospitals, psychiatric hospitals, and other specialty hospitals (e.g., alcoholism, maternity). The 2017 survey is the most recent N-SSATS that asked respondents about EHR adoption and electronic HIE; it had an overall response rate of 89.2%. This study was not human subjects research; therefore it did not require approval by the Institutional Review Board.

Primary outcomes of interest

We examine two primary outcomes reported by hospital-based substance use disorder programs in the 2017 N-SSATS: 1) adoption of basic EHR functional features, and 2) use of electronic HIE.

The N-SSATS EHR adoption questions corresponded with the ONC’s, but did not entirely match. Therefore, we used the N-SSATS responses to create an indicator of basic EHR adoption which approximated the ONC’s definition as closely as possible. We defined basic EHR features in the N-SSATS as electronic/computer sources to accomplish the following clinical tasks: 1) assessment, 2) client progress monitoring, 3) discharge, 4) issue/receive lab results and, 5) medication prescribing and dispensing (see Table 1 for comparison of functional features examined for basic adoption between the ONC and N-SSATS). In contrast, the definition of HIE in the N-SSATS is the same as the ONC’s (i.e., “do you use HIE to send client health and/or treatment information to providers or sources outside of your organization”).

Table 1:

EHR functional features of basic EHR adoption in ONC definition and corresponding 2017 N-SSATS functional features.

ONC definition	Corresponding N-SSATS functional features
Electronic Clinical Information
Patient demographics	-------
Physician notes Nursing assessments	Assessment Treatment plan Client progress monitoring
Problem lists	-------
Medication lists	-------
Discharge summaries	Discharge
Computerized Provider Order Entry
Medications	Medication prescribing/dispensing
Results Management of Information—View
Lab reports	Issue/receive lab reports
Radiology reports	------
Diagnostic test results	------

Note: ----- denotes item not included in N-SSATS.

A further difference between the ONC and N-SSATs is that the ONC definition asks about adoption in “at least one unit of the hospital;” whereas, the N-SSATS asks respondents to “indicate if staff members routinely use computer or electronic resources, paper only, or a combination of both to accomplish their work” in their program(s). In the N-SSATS, electronic resources are defined as “include tools such as electronic health records and web portals,” and paper documents are defined as “PDFs, scanned documents, or e-fax”. To approximate the ONC’s definition of “in at least one unit of the hospital”, we defined adoption of basic EHR or electronic HIE as occurring if a hospital used “any” computer/electronic source (i.e., computer/electronic only or both paper and electronic/computer) in a substance use disorder program. We used “any” for our definition, given that a hospital may have more than one substance use disorder treatment program or unit (e.g., in different levels of care) and it is possible that EHR features were adopted in one but not (or not yet) all of the programs (hence a mix of paper and computer use).

Explanatory Variables

Explanatory variables examined included: hospital type (general acute care hospitals, psychiatric hospitals, other specialty hospitals), hospital profit status (non-profit, for-profit, government hospital), whether the program accepts Medicaid, and whether it provides medication treatment for opioid or alcohol use disorders (methadone, naltrexone, buprenorphine, acamprosate or disulfiram). Hospital characteristics such as hospital type and profit status have been associated with EHR adoption and HIE previously in the literature (including in behavioral health hospital settings).^18,20,23,24 We also examined whether a program accepts Medicaid, because Medicaid is a predominant payer of substance use disorder services.²⁵ Finally, we examined whether a program provides medications to treat alcohol or opioid use disorders, because: 1) the important role of EHRs in healthcare safety and quality associated with medication use and prescribing, and 2) access to medication treatment is a measure of quality of a substance use disorder program in general. We also created a variable that described the highest level of substance use disorder care provided by the organization (inpatient, residential, intensive outpatient/partial hospitalization, and regular outpatient), because health information technology (HIT) is likely to be most beneficial when managing care for patients with complex medical needs and who are the sickest.

Statistical Analysis

We calculated descriptive statistics of the characteristics of hospital-based substance use disorder programs, and conducted bivariate analyses of associations between the explanatory variables and each primary outcome. We then fit multivariable logistic regression models for our two outcomes. In the model of electronic HIE, we also included the indicator for EHR adoption as a predictor. To address respondents with missing outcome information, we followed missing value approach used in prior research on EHR adoption.²⁶ Specifically, we estimated the probability of each respondent having a missing outcome and then weighted non-missing respondents by 1/(1-probability of having missing outcome). Using this approach, respondents with non-missing outcomes compensate for similar respondents with missing outcomes, and thus reduce the risk of bias. We estimated predicted probabilities (PP) for significant predictors following each model. We tested the sensitivity of our specifications of the outcomes by fitting models where missing values on the outcome variables were forced into the “no” category.

Results

There were 1,024 hospitals with substance use disorder programs in the 2017 N-SSATS. In unadjusted analyses, we excluded 130 (12.7%) hospitals from the EHR analyses and 185 hospitals (18.1%) from the HIE analyses due to missing outcome information. Of the 894 facilities with outcome information that were included in the EHR adoption analysis, two-thirds (67.8%) met our study criteria for adopting basic EHR functionality (Table 2). Of the 839 hospitals with outcome information for use of HIE, 71.3% reported using electronic HIE. (See the online supplement for differences in characteristics by missingness and for a consort diagram explaining patterns of missingness.) Compared to hospital based programs that did not adopt basic EHR functionality, those that did were more likely to be in acute care general hospitals, non-profit, provide substance use disorder medications, and offer routine outpatient as their highest level of care. The patterns for use of electronic HIE were similar across facility types and ownership categories, as well as in having routine outpatient as the highest level of care. When limiting our analysis to hospital-based programs in acute care general hospitals, EHR and electronic HIE adoption were at 74.9% and 74.1%, respectively (data not shown).

Table 2:

Facility characteristics and use of a basic electronic health record or health information exchange among hospital-based 2017 N-SSATS substance use disorder programs

Electronic Health Recordsa
	Total (N = 894)		Yes EHR (N = 606)		No EHR (N = 288)		χ2	Degrees of freedom	p
	N	Column %	N	Row %	N	Row %
Facility Type
Psychiatric hospital	268	30.0	137	51.1	131	48.9	48.7	1	<0.001
General hospital	589	65.9	441	74.9	148	25.1	39.7	1	<0.001
Other hospital	37	4.1	28	75.7	9	24.3	1.1	1	0.29
Ownership
For-profit	196	21.9	82	41.8	114	58.2	77.4	1	<0.001
Non-profit	576	64.4	446	77.4	130	22.6	69.0	1	<0.001
Governmentb	122	13.6	78	63.9	44	36.1	1.0	1	0.33
Accepts Medicaid c	726	81.2	503	69.3	223	30.7	2.8	1	0.10
Provides substance use disorder medications d	729	81.5	511	70.1	218	29.9	9.7	1	<0.001
Highest level of care
Inpatient	420	47.0	282	67.1	138	32.9	0.2	1	0.70
Residential	51	5.7	32	62.7	19	37.3	0.6	1	0.43
Intensive outpatient/partial hospital	280	31.3	183	65.4	97	34.6	1.1	1	0.29
Routine outpatient	143	16.0	109	76.2	34	23.8	5.6	1	0.02
Health Information Exchangee
	Total (N = 839)		Yes HIE (N = 598)		No HIE (N = 241)		χ2	Degrees of freedom	p
	N	%	N	%	N	%
NSSATs items
Facility Type
Psychiatric hospital	227	27.1	146	64.3	81	35.7	7.4	1	0.01
General hospital	563	67.1	417	74.1	146	25.9	6.5	1	0.01
Other hospital	49	5.8	35	71.4	14	28.6	0.0	1	0.98
Ownership
For-profit	174	20.7	103	59.2	71	40.8	15.7	1	<0.001
Non-profit	543	64.7	402	74.0	141	26.0	5.7	1	0.02
Governmentb	122	14.5	93	76.2	29	23.8	1.7	1	0.19
Accepts Medicaid c	674	80.3	479	71.1	195	28.9	0.1	1	0.79
Provides substance use disorder medications d	631	75.2	450	71.3	181	28.7	0.0	1	0.96
Highest level of care
Inpatient	351	41.8	251	71.5	100	28.5	0.0	1	0.90
Residential	56	6.7	42	75.0	14	25.0	0.4	1	0.52
Intensive outpatient/partial hospital	294	35.0	197	67.0	97	33.0	4.0	1	0.05
Routine outpatient	138	16.4	108	78.3	30	21.7	4.0	1	0.05

^aExcludes hospitals missing outcome information for basic EHR adoption (N missing = 130).

^bIncludes: state, local/county/community, tribal, or federal government. There were no Veterans Affairs hospitals in sample.

^cMedicaid payment has 10 missing; therefore, these 10 are missing from the denominator in the percentages shown.

^dIncludes medications for alcohol or opioid use disorder (naltrexone, buprenorphine, methadone, acamprosate, or disulfiram).

Programs in psychiatric hospitals had lower odds of basic EHR adoption relative to those in acute care general hospitals (OR[95%CI]=0.49[0.35–0.71], PP=0.56 versus PP=.73 respectively [Table 3 and 4]). Programs in for-profit or government-owned hospitals also had lower odds of basic EHR adoption (0.23[0.16–0.35], PP = 0.42 and 0.52[0.33–0.83], PP=0.56, respectively) compared to those in non-profit hospitals (PP=0.75). Providing substance use disorder medications was associated with greater odds (1.95[1.31–2.90], PP=0.70 vs. PP=.57); while having intensive outpatient/partial hospitalization as the highest level of care relative to regular outpatient was associated with lower odds of basic EHR adoption (0.49[0.29–0.81], PP=0.62 vs. PP=0.75). In the logistic model predicting use of HIE, only adoption of basic EHR functionality was associated with electronic HIE use (4.73[3.29–6.79], PP=0.81 vs. PP=0.48). The results of the sensitivity analysis were qualitatively unchanged from our primary analysis.

Table 3:

Multivariable logistic regression models adjusted for facility characteristics of hospitals with substance use disorder programs that adopted basic EHR or electronic HIE in 2017 N-SSATS

	Basic EHR N = 886a			HIE with EHR N = 742b
	OR	95% CI	p	OR	95% CI	p
Hospital type (ref = general acute care hospital)
Psychiatric hospital	0.49	0.35, 0.71	<0.001	0.84	0.56, 1.27	0.41
Other hospital	1.18	0.46, 3.06	0.73	1.10	0.46, 2.67	0.83
Ownership (ref = nonprofit)
For-profit	0.23	0.16, 0.35	<0.001	1.02	0.64, 1.63	0.92
Government	0.52	0.33, 0.83	0.01	1.51	0.88, 2.57	0.13
Accepts Medicaid	1.21	0.80, 1.81	0.37	0.89	0.56, 1.41	0.61
Provides substance use disorder medications	1.95	1.31, 2.90	<0.001	0.86	0.56, 1.32	0.49
Highest level of care (ref = routine outpatient)
Intensive outpatient/partial hospital	0.49	0.29, 0.81	0.01	0.70	0.41, 1.21	0.20
Residential	0.73	0.32, 1.66	0.46	1.05	0.46, 2.38	0.91
Inpatient	1.14	0.69, 1.89	0.61	0.95	0.54, 1.66	0.85
Basic EHR				4.73	3.29, 6.79	<0.001
Constant	2.52	1.37, 4.63	<0.001	1.31	0.64, 2.70	0.46

^aN = 886 due to 130 respondents missing outcome information for basic EHR adoption and eight additional hospitals missing information on Medicaid payment.

^bN = 742 due to 185 respondents missing outcome information for HIE adoption, 92 additional hospitals missing information on basic EHR adoption, and five additional hospitals missing information on Medicaid payment.

Table 4:

Predicted probabilities (PP) of significant predictors from the weighted multivariable logistic regression models in 2017 N-SSATS

	PP	95% CI
Outcome = basic EHR adoption
Psychiatric hospital	0.56	0.50, 0.63
General acute care hospital	0.73	0.69, 0.77
For-profit	0.42	0.34, 0.50
Nonprofit	0.75	0.72, 0.79
Government	0.56	0.47, 0.64
Provides substance use disorder
medications	0.70	0.67, 0.73
Does not provide substance use disorder
medications	0.57	0.49, 0.64
Highest level of care is intensive/partial
hospitalization	0.62	0.56, 0.67
Highest level of care is routine outpatient	0.75	0.68, 0.82
Outcome = Electronic HIE
Has basic EHR	0.81	0.78, 0.85
Does not have basic EHR	0.48	0.42, 0.55

Discussion

In this national sample of hospital-based substance use disorder treatment programs, we found that adoption of basic EHR functionality and electronic HIE to send information to outside providers lag behind general adoption of EHR and use of HIE in acute care hospitals (84% and 88% respectively).^14,15 About two-thirds (67.8%) of the hospital-based programs reported adopting basic EHR functionality, and 71.3% reported sending electronic HIE to outside providers. Prior work has found that psychiatric hospitals have low rates of basic EHR adoption.^14,24 Since the programs in our sample were disproportionately located in psychiatric hospitals, it is not surprising that an overall estimate of basic EHR adoption among hospital-based substance use disorder programs is lower than the ONC estimates. However, even when limiting our analyses to hospital-based programs in acute care general hospitals, EHR adoption as well as HIE were lower (74.9% and 74.1%, respectively) than in prior literature of basic EHR adoption/HIE occurring in acute care hospitals overall (84% and 88%, respectively).^14,15

Our findings suggest that – compared to adoption at the overall hospital level – there are unique barriers to EHR adoption and HIE use among hospital-based substance use disorder programs. Patients with substance use disorders are known to experience stigma related to their illness, including by health care professionals.²⁷ Possibly these experiences have led some programs to be reluctant to implement EHRs. Another potential barrier, as noted earlier, may be that the federal 42 CFR Part 2 privacy requirements are more stringent than HIPAA. Additionally, some states have privacy laws that are more stringent than Part 2.²⁸ Part 2 has been criticized as making it difficult for substance use disorder treatment information to be documented in EHRs.^29,30 In February 2017, and more recently (July 2020), SAMHSA updated the Part 2 regulations to address these concerns.^31,32 Our data, from the 2017 N-SSATs, is unlikely to reflect any changes that may have occurred due to these updates to Part 2. Future research is needed to understand whether, or to what extent, the updates to Part 2 have enabled broader adoption of EHRs and HIE use in substance use disorder treatment settings.

Compared to non-profit hospitals, substance use disorder programs based in for-profit and government hospitals were less likely to have adopted basic EHR functionality, which reflects similar patterns in EHR adoption more broadly.¹⁸ This finding is notable considering the rise of for-profit substance use disorder treatment programs in the US. While most concerns about for-profit substance use disorder treatment programs have focused on lack of evidence-based treatments, structures like use of a basic EHR and electronic HIE are foundational to a wide-range of quality assessment and improvement activities. However, we did not find ownership to be a significant predictor of HIE, mirroring a similar finding from a recent study of electronic HIE among inpatient psychiatric units of acute care hospitals.²³ Differences by ownership among hospital-based providers, therefore, appear to be related to initial investment into HIT infrastructure, and not necessarily the use of existing HIT for information sharing at discharge.

Hospital-based substance use disorder treatment programs that provided medications for alcohol or opioid use disorders were associated with adoption of basic EHR functionality. Given the medication-safety benefits of EHRs, this is a welcome finding. Still, a note of caution in interpreting these results is that the N-SSATS survey only asks about one component of EHR-based medication information/functionality—that is, prescribing or dispensing. An important EHR safety and quality feature that is also a part of the ONC definition of basic EHR functionality, but not information collected in the N-SSATS, is the presence of a medication list. Surprisingly, we did not find that organizations offering higher intensity levels of substance use disorder care were more likely to adopt basic EHR or electronic HIE. In fact, providers offering intensive outpatient/partial hospitalization were less likely to adopt basic EHR; further research is needed to understand why this is.

The strongest predictor of electronic HIE from hospital-based substance use disorder programs was having adopted basic EHR functionality. This is not surprising given that EHRs would be a primary vehicle by which patient electronic health information could be exchanged. Still, it highlights that if policy makers want to increase opportunities to improve the quality and safety of care enabled by electronic HIE from substance use disorder programs, more efforts will be needed to encourage EHR adoption among specialty substance use disorder providers. Additionally, EHR adoption in psychiatric hospitals face challenges. Psychiatric hospitals were ineligible for the incentives available to general acute care hospitals from the federal Health Information Technology for Economic and Clinical Health (HITECH) Act. The HITECH Act, which provided hospitals with financial assistance and incentives to adopt EHRs, was credited as a success in spurring health information technology (HIT) adoption in eligible hospitals.¹⁹ No such similar program has been specifically enacted for psychiatric hospitals, but the 2018 Support Act could potentially provide the means to investigate such a policy. It allows the Centers for Medicare and Medicaid Innovation to test incentive demonstration models for EHR adoption in behavioral health settings.³³ As yet, no demonstration program of this type has been announced.

An important limitation of this study is that the N-SSATS HIT items do not entirely align with the definitions of basic EHR adoption and HIE use specified by the ONC. To the extent that this study misclassifies whether a program has adopted basic EHR technology or uses electronic HIE, we expect our estimates are an overestimate compared to the ONC’s. Another limitation is that we were limited to hospital characteristics available in the N-SSATS in our study. The N-SSATS database does not include hospital identifiers. Therefore, we were unable to supplement the data with other publicly available hospital/facility data, including information previously associated with EHR adoption/HIE use in hospitals and psychiatric units (e.g., hospital size,^20,21,23 or participation in an accountable care organization²³). Finally, as we note above, these data were from 2017 – the most current year available– which might not reflect current rates of EHR and HIE adoption.

These differences between the N-SSATS and the ONC definitions is problematic from a health policy perspective. The N-SSATS is a missed opportunity to better compare adoption of electronic technology in substance use disorder hospital-based programs to those in acute care hospitals overall. Recent work by members of this investigator team has identified a similar issue in the Centers for Medicare and Medicaid Services’ (CMS) Inpatient Psychiatric Facility Quality Reporting Program.²³ In addition to N-SSATS, SAMHSA’s National Mental Health Services Survey (N-MHSS) is similarly challenging for measuring EHR adoption and HIE. Given the importance of HIT in the quality and safety of health care, important future policy efforts should be to not only encourage adoption in behavioral health treatment settings, but also to apply consistent definitions of adoption to behavioral health settings, as are used elsewhere in healthcare settings and by policy makers.

Conclusion

The adoption of HIT that could improve the quality and safety of hospital-based substance use disorder specialty care lags behind hospital-based treatment settings more broadly. This finding is not entirely accounted for by HIT adoption in psychiatric hospitals (which is known to lag behind adoption in acute care hospitals), but it appears there are additional barriers to EHR/HIE use in acute care general hospital based substance use disorder treatment settings as well (possibly related to 42 CFR Part 2). Understanding the extent to which HIT adoption lags in specialty behavioral health programs would be improved by better alignment across the ONC, CMS, and SAMHSA surveys that examine such adoption.