This study of VA outpatients from eight sites where providers routinely used clinical reminders found that providers used a passive alcohol counseling clinical reminder for 71% of patients who screened positive for unhealthy alcohol use over a 2-year period. This percentage was consistent with results from the first 8 months after implementation of the reminder 22
and substantially higher than the 28% of VA outpatients with unhealthy alcohol use who reported advice on a national satisfaction survey during the same period.13
Moreover, among patients with unhealthy alcohol use, those who had reminder use were significantly more likely to report having resolved unhealthy alcohol use at follow-up.
Previous studies have demonstrated that patients are more likely to receive brief alcohol counseling if they have more severe unhealthy alcohol use.7,9–12
In contrast, in the present study, there were no significant differences in measures of severity between patients with and without reminder use. Further, factors significantly associated with resolution of unhealthy alcohol use differed for patients with and without reminder use. These findings suggest that the reminder might counteract the inclination of providers to primarily counsel only patients with the most severe unhealthy alcohol use. Although no study has addressed this question for unhealthy alcohol use, a recent review found that use of clinical reminders helps reduce disparities in provision of preventive care across racial/ethnic groups.32
Despite the ability of electronic clinical reminders to improve provision of preventive care for multiple conditions, 15
associations between clinical reminder use and improved patient outcomes have typically been small or undetectable.15,33,34
Similarly, patients in this study whose providers used the alcohol counseling clinical reminder had a modest but significant increase in resolution of unhealthy alcohol use at follow-up compared to patients without reminder use. Randomized controlled trials of brief alcohol counseling have had much larger effects.3
To our knowledge no health-care system has achieved sustained implementation of brief alcohol counseling for patients who screen positive for unhealthy alcohol use,35,36
and implementation research programs have had positive but not sustained impact.37,38
Only one previous study has tested an electronic clinical decision support system as a method of implementing alcohol screening and counseling.39
In that study, the clinical decision support system was coupled with academic detailing, and 51% of screen-positive intervention patients had documented counseling compared to 30% in control clinics.39
Although that rate was substantially higher than in previous implementation efforts without clinical reminders,38,40
it is unknown whether rates of screening and counseling were sustained after study termination. Our finding that 71% of all patients who screened positive for unhealthy alcohol use had use of the alcohol counseling reminder is high relative to previous studies 38–40
and was sustained for 2 years without any other intervention.22
While there was a national VA performance measure for alcohol screening tied to incentives for VA Network Directors, there was no such performance measure for brief alcohol counseling during this study.13,22
The ability of the clinical reminder to move brief alcohol counseling onto the busy clinical agenda for patients irrespective of the severity of unhealthy alcohol use at this VA facility was an important first step toward implementation. However, it is unknown whether these findings will be replicated at VA or non-VA sites where clinical reminder use is not routine. Further, there is no consensus on the “active ingredients” of brief alcohol counseling,22
but advice and feedback offered in an empathetic, patient-centered manner41
are common components of most effective brief alcohol counseling interventions. It is unclear whether providers are prepared to offer effective counseling in the absence of education and coaching, even when prompted.42,43
Trials of brief alcohol counseling with the largest effects4,44
have included in-depth education for providers, often including principles of motivational interviewing.45
Our finding that use of the clinical reminder was associated with modest increases in resolution of unhealthy alcohol use at follow-up screening may reflect that some providers have the necessary skills to offer effective brief alcohol counseling43
or that the actual content of the counseling is less important than the fact that a provider raised the issue of drinking with patients who screen positive.3,46
Additional research is needed to evaluate the quality of counseling offered when reminders are used to prompt providers to counsel patients in real world settings, and to determine educational needs of providers and efficient approaches to meeting them.
This study has several limitations. Findings regarding decreased drinking after brief alcohol counseling could reflect biased reporting by patients. Patients may be more likely to under-report alcohol consumption after they have received brief alcohol counseling. This might be especially true if providers included recommended drinking limits in their counseling as they were prompted to do by the clinical reminder. Further research is needed to establish the validity of changes in alcohol screening scores as a measure of changes in drinking. Despite adjustment for many important covariates, the observed association between reminder use and resolution of unhealthy alcohol use may also reflect bias by indication or residual confounding due to limitations of secondary clinical and administrative measures. In particular, our use of administrative diagnostic data to measure potential confounders likely underestimates prevalence, especially tobacco and other substance use disorders and psychiatric comorbidities.47
Finally, use of a clinical reminder and secondary electronic data to evaluate implementation of brief alcohol counseling has limitations. First, only brief alcohol counseling documented using the clinical reminder is captured. Second, although we labeled elements of the alcohol counseling clinical reminder with unique data elements, clinical reminder labels are editable locally in the VA. Third, although use of merged secondary data allowed us to capture use of the clinical reminder, we were unable to link patients to particular primary care providers or measure provider characteristics. Previous studies have identified considerable variability in use of clinical reminders across providers. 21,48
It is likely that provider characteristics contributed to whether or not, and how, the reminder was used.49,50
Finally, because clinical reminder data are only stored locally in the VA, the evaluation relied on merging local data with national clinical and administrative data, limiting the ability of this study to compare changes in AUDIT-C scores at this site with other sites.
Despite these limitations, this study has noteworthy strengths. It is the first study to our knowledge to evaluate an electronic clinical reminder alone as a method of implementing brief alcohol counseling—in the absence of other systematic interventions. Moreover, we evaluated the clinical reminder in a naturalistic setting among a large population of outpatients from a multi-site health-care system, thereby mitigating the potential for selection or measurement bias due to recruitment of and interaction with providers or patients. Finally, administrative data were used to adjust analyses for five measures of alcohol use severity.
We found that a substantial majority of patients with unhealthy alcohol use had documented use of the alcohol counseling clinical reminder and that rates of use did not differ markedly based on the severity of unhealthy alcohol use. Further, we found that use of the alcohol counseling clinical reminder was associated with significantly greater resolution of unhealthy alcohol use at follow-up screening, even after adjustment for multiple measures of alcohol use severity. These findings support the feasibility of using clinical reminders in EMRs to increase brief alcohol counseling in real-world settings where clinical reminder use is routine. Further research is needed to replicate findings at other sites and to evaluate the quality of counseling, educational needs of providers, and validity of changes in alcohol screening scores as a surrogate outcome after brief alcohol counseling.