PROJECT SUMMARY Unhealthy alcohol use (the spectrum from risky consumption through alcohol use disorder, AUD) is a leading cause of preventable death, and alcohol-related health harms (e.g. AUD itself, cirrhosis) are increasing. Most people with unhealthy use receive no effective interventions despite the high frequency of contact with medical care. Electronic health records (EHRs) can be leveraged to improve the identification and effective treatment of AUD. Some integrated health systems have leveraged EHRs but examples not supported by such substantial infrastructure are uncommon, and the full potential to manage populations in accountable care organizations beyond screening and brief preventive counseling has not been realized. This research is aimed at improving services for AUD by using EHRs to support individual care and population health management in urban primary care based at a hospital with an accountable care organization (ACO) in a diverse underserved community. The over-arching goal of the proposed project (RACE-Records for Alcohol Care Enhancement) is to use data already being collected in routine clinical practice in EHRs to improve clinical identification and management of people with AUDs. To achieve that goal we will, in the first phase of this project, 1) create a clinically useful live database of patients with unhealthy alcohol use and implement prompts and decision support (“best practice advisory” or alert, BPA) and practice level monitoring in an urban underserved community ACO, 2) access and automate linkage of inpatient and outpatient (including emergency department visit) EHR data and primary care in-person-collected alcohol screening data, 3) create a usable registry of primary care patients with alcohol use disorder from the linked EHR and screening data, 4) adapt the EHR to create a best practice advisory to alert clinicians of their patients’ unhealthy alcohol use and provide guidance for clinical action, and then 5) create a data collection and capture method to monitor and report on alcohol use and alcohol consequence-related healthcare visits for the panel of patients in the registry at the individual and practice levels before and after implementation of the EHR changes. In the second phase of the project, we will test feasibility and obtain preliminary effectiveness estimates in a 4-arm randomized trial comparing EHR 1) clinician prompting and decision support best practice advisory alone (BPA), 2) BPA plus population health management (BPA+PHM), 3) BPA plus clinical care management (BPA+CCM) and 4) all three (BPA+PHM+CCM), to improve AUD care. We hypothesize that compared to BPA alone (arm 1), PHM (arm 2) and CCM (arm 3) separately and all 3 together (arm 4) will improve engagement (a national quality of care measure), receipt of AUD medication, AUD counseling, and specialty AUD care by referral. The study will demonstrate the feasibility of leveraging EHRs in widespread use, and will inform likely effectiveness for improving care that could lead to better clinical outcomes from less heavy drinking to fewer emergency department visits for alcohol-related care, thereby reducing alcohol-related morbidity and mortality in the US.

PROJECT NARRATIVE The prevalence of alcohol use disorder is on the rise, people with it commonly visit general health settings, and there are effective treatments, yet few receive those treatments. Electronic health records have potential to improve care for alcohol use disorders. This project will study ways of using the electronic record combined with population health and care management to get better science-based effective care to people with alcohol use disorder who can benefit from it.