This CDS artifact facilitates evidence-based alcohol screening with the AUDIT as outlined by the World Health Organization (WHO) to identify adults drinking in excess of recommended levels.The logic includes progression from an alcohol prescreen question (i.e., Do you sometimes drink beer, wine or other alcoholic beverages?) to the WHO AUDIT-C and onto the full WHO AUDIT, when indicated.
Artifact Creation and Usage
This artifact was developed by MITRE software engineers and clinical informaticists in collaboration with clinical subject matter experts and leaders from the Centers for Disease Control and Prevention (CDC) National Center on Birth Defects and Developmental Disabilities (NCBDDD).
- Additional information about MITRE's health expertise is available at https://health.mitre.org/.
- Additional information about the CDC's alcohol and public health work is available at https://www.cdc.gov/alcohol/index.htm.
- Additional information about the CDC NCBDDD is available at https://www.cdc.gov/ncbddd/index.html.
© 2022 The MITRE Corporation. All Rights Reserved. Approved for Public Release: 20-1501. Distribution and Use of Artifacts and Associated Documentation Unlimited.
The CDS flow diagram pictured here provides a high level overview of the screening flow and some of the decision points specified in the CDS logic.
The implementation guide for this artifact is available on GitHub here.
The semi-structured (i.e., human readable, Level 2) representation of the artifact is available in Appendix A of the implementation guide for this artifact. The structured (i.e., coded) CDS logic is attached to this artifact in the Logic File field. The code is expressed using Clinical Quality Language (CQL) and the Fast Healthcare Interoperability Resources (FHIR) Release 4 (R4) data model. All value sets referenced in the logic are published on the Value Set Authority Center (VSAC). Additional details about these resources can be accessed via the following URLs:
- CQL: https://ecqi.healthit.gov/cql-clinical-quality-language
- FHIR R4: https://hl7.org/fhir/R4/resourcelist.html
- VSAC: https://vsac.nlm.nih.gov/
Open source resources associated with this CDS are available on GitHub here. The resources include:
- asbi-intervention-app: a SMART on FHIR application that provides CDS interventions based on alcohol screening scores and patient information to assist clinicians with caring for patients based on their alcohol use
- asbi-screening-app: a SMART on FHIR application that provides multiple alcohol screening instruments for assessing a patient's alcohol use
- questionnaire-to-survey: a library for incorporating FHIR Questionnaires into SurveyJS
- asbi-testing-server: a node-based FHIR server to be used for testing alcohol screening and brief intervention CDS
Executable code that is interpretable by a CDS system at a local level. This will vary for each particular site
This CDS identifies adults for whom alcohol screening is indicated. It delivers a series of screening questions that align with guidelines published in AUDIT: The Alcohol Use Disorders Identification Test, Guidelines for Use in Primary Care (Babor et al., 2001). The resulting WHO AUDIT-C/WHO AUDIT score can then guide a clinician in discussing the patient's use of alcohol.
This CDS is intended for adults (i.e., individuals 18 years old and older).
This artifact is intended for use by healthcare personnel working in primary healthcare settings who care for adults. The WHO AUDIT manual states that the AUDIT may be appropriate in the following settings also: emergency room, physician's surgery room, general hospital wards, outpatient clinics, psychiatric hospitals, military services, and workplace employee assistance programs (Babor et al., 2001).
|This artifact does not include care recommendations (e.g., brief interventions): The CDS Development Team and CDC sponsors of this work took a modular approach to developing alcohol screening and brief intervention (ASBI) CDS artifacts to 1) lessen the complexity of each artifact and 2) enable organizations to only integrate portions of logic that they really need (e.g., are not already present in their health information technology [IT] system). A modular approach allows for personalized implementation choices without the need to edit CDS code. The Brief Behavioral Counseling Interventions for Excessive Alcohol Consumption with Optional Referral to Treatment and Facilitating Shared Decision Making For People Who Drink Alcohol: A Patient Decision Aid artifacts (also available on the CDS Connect Repository) are integral companion CDS modules to this artifact if a healthcare organization does not have ASBI care recommendations implemented in their health IT system.
|This artifact aligns with WHO AUDIT guidelines, as opposed to USAUDIT guidelines: The WHO AUDIT was created to screen for excessive drinking using a "standard" drink size of 10 grams of alcohol (Babor et al., 2001), whereas the USAUDIT defines a standard drink as containing 14 grams of alcohol (Babor, Higgins-Biddle & Robiana, 2018). As such, the responses to questions 1, 2 and 3, and the wording of question 3, vary between each questionnaire, as does the scoring and a few other specifics. Prior to implementing this CDS, it is important to consider which version of the AUDIT is most appropriate for the country where this CDS may be utilized since the types and amounts of alcoholic drinks will vary according to culture and custom (Babor et al., 2001).
|Consider the value of implementing an alcohol screening questionnaire that evaluates numerous aspects of alcohol use:
Healthcare organizations that have implemented brief screening questionnaires (e.g., the Single Alcohol Screening Question [SASQ]) or multi-substance screening questionnaires that do not broadly evaluate numerous aspects of a patient’s use of alcohol (e.g., the NIDA QS, the NIDA Modified Assist) as “stand alone” alcohol screening questionnaires are encouraged to consider implementing either version of the full AUDIT in their health IT system to evaluate the full spectrum of a patient’s use of alcohol if the patient screens positive on one of the aforementioned questionnaires. Integration of this Alcohol Screening Using the WHO AUDIT artifact or the Alcohol Screening Using the USAUDIT artifact with a brief alcohol screening assessment can provide additional, valuable insight into the patient’s alcohol consumption, which in turn can inform more appropriate patient-centered brief interventions and care.
|All care provided to the patient should be subject to clinical judgement: Clinicians are encouraged to consider the patient's medical condition, family history of alcohol problems and perceived honesty in responding to the AUDIT questions prior to making care decisions related to the patient's alcohol use (Babor et al. 2001).
|Implementation Note: This artifact is not “standalone”. It is not intended to be completely plug-and-play (i.e., healthcare systems will need to integrate the artifact with components of their health IT system for the artifact to work). Implementers should conduct extensive testing, including clinical testing in real-life workflows. It is expected that artifacts will be customized and adapted to local clinical and IT environments.
The development of this artifact was informed by the evidence-based references listed below.
Babor, T. F., Higgins-Biddle, J. C., & Robaina, K. (2017). The Alcohol Use Disorders Identification Test, Adapted for Use in the United States: A Guide for Primary Care Practitioners, 24. Retrieved from https://www.ct.gov/dmhas/lib/dmhas/publications/USAUDIT-2017.pdf
Babor, T. F., Higgins-Biddle, J. C., Saunders, J. B., & Monteiro, M. G. (2001). The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care. Retrieved from https://www.who.int/substance_abuse/publications/audit/en/
Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., Davidson, K. W., … Wong, J. B. (2018). Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement. JAMA - Journal of the American Medical Association, 320(18), 1899–1909. https://doi.org/10.1001/jama.2018.16789
Centers for Disease Control and Prevention. (2014). Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use A Step-by-Step Guide for Primary Care Practices. Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities. Retrieved from https://www.cdc.gov/ncbddd/fasd/documents/AlcoholSBIImplementationGuide.pdf
Decisions made while developing this CDS are outlined in Appendix A of the accompanying implementation guide for this artifact.