The feasibility of integrating an alcohol screening clinical decision support tool into primary care clinical software: A review and Australian key stakeholder study

doi:10.21203/rs.3.rs-3784356/v1

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Research Article

The feasibility of integrating an alcohol screening clinical decision support tool into primary care clinical software: A review and Australian key stakeholder study

https://doi.org/10.21203/rs.3.rs-3784356/v1

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Background: This study explored the feasibility of integrating a clinical decision support tool into general practice clinical management software in Australia to prompt for alcohol screening among patients who are pregnant or planning a pregnancy. The study aimed to increase understanding of what is an appropriate and acceptable clinical decision support tool, the circumstances when a prompt to use such a screening tool should occur, and the barriers and enablers of successful implementation.

Methods: This research study employed a mixed methods approach and purposive sampling to identify key stakeholders to interview. Participants included vendors of clinical software used in Australian general practice, clinicians in general practice, and relevant others. Data from a literature review and 23 interviews were analysed leading to recommendations which were ‘sense-tested’ by an additional 22 stakeholders.

Results: Although there are at least 18 clinical software packages used in Australian general practice, it is feasible to integrate an alcohol screening tool for pregnancy into software for the majority of general practices in Australia. The AUDIT-C alcohol screening tool for pregnancy was widely accepted as suitable for such a purpose. Clinicians suggested the greatest barriers to screening were lack of time within antenatal consultations and insufficient remuneration for longer consultations. Many clinicians saw opportunity for introducing a multifunctional antenatal tool that could incorporate screening and clinical decision support for alcohol, tobacco and other substance use, mental health, domestic and family violence and potentially other areas informing healthy pregnancy. It could also be used opportunistically for preconception screening and counselling. Deployment of the tool could be supported by an education campaign from professional associations.

Conclusion: The integration of a tool for screening for alcohol use among women who are pregnant or planning pregnancy into general practice clinical software is feasible; however, a multifunctional antenatal screening tool, incorporating other psychosocial elements, was considered more useful than a stand-alone alcohol screening tool. Further work is needed with vendors and end-users to develop an acceptable tool that can be widely implemented. Issues with GP renumeration need also to be addressed to encourage alcohol screening pre-pregnancy and in the early months of pregnancy.

Alcohol Use

Antenatal Care

Australia

Clinical Decision Support Systems

Feasibility Studies

General Practice

Harm Reduction

Preconception Care

Pregnancy

Software Tools

It is well established that alcohol used during pregnancy can cross the placenta and cause significant harm to the developing baby including lower birth weight, increased risk of miscarriage, premature birth and Foetal Alcohol Spectrum Disorders (FASD)[1–3]. FASDs are characterised by impaired neurodevelopmental, congenital anomalies and poor growth, are a leading cause of preventable birth defects and disability and can have ‘profound’ social and economic effects [1].

Alcohol consumption in pregnancy is a behaviour that spans demographics, including ethnicity, socioeconomic status, and education levels. There is research to suggest that where clinicians selectively conduct antenatal alcohol screening, they tend to under-screen patients who are the most likely to drink alcohol during pregnancy [4–6]. Health care professionals often assume that older, more affluent and well-educated women are less likely to continue to consume alcohol during pregnancy, whereas research suggests the opposite can be true [7–10]. In Australia, rates of alcohol use among pregnant and breastfeeding women are falling according to the National Drug Strategy Household Survey, yet some 55% of respondents reported consuming alcohol before they are aware of their pregnancy, and 14.5% continued to drink alcohol after they knew they were pregnant (Australian First Nations and homeless people are underrepresented in the survey) [11].

To reduce harm caused by alcohol consumption during pregnancy, both Australian and international primary and obstetric care guidelines recommend healthcare professionals should inform patients of the risks of prenatal alcohol exposure and advise their patients safest course of action is to abstain from alcohol entirely during pregnancy [12–20]. Despite this, rates of harm related to prenatal alcohol exposure continue to be high [11, 16, 21].

The most recent Australian National Health Medical Research Council (NHMRC) Guidelines to Reduce Health Risks from Drinking Alcohol are unequivocal in their recommendation: ‘To prevent harm from alcohol to their unborn child, women who are pregnant or planning a pregnancy should not drink alcohol’ and that ‘the evidence does not indicate a safe amount of alcohol that pregnant women and breastfeeding mothers can drink’ [16]. This messaging may be diluted in Australian Clinical Practice Guidelines for Pregnancy Care (2020) which highlight that health professionals should advise that the risk is higher with high alcohol intake, the risk appears to be low with low alcohol intake, and that ‘it is impossible to determine how other maternal and foetal factors will alter risk in the individual.’ [15].

Primary care services in Australia provided by general practitioners (GPs–i.e., family physicians), practice nurses, and Aboriginal Health Workers are subsidised by public/government funding through the Medicare Benefits Scheme (Australia’s publicly universal health care insurance scheme–referred to below as ‘Medicare’). Despite the subsidy, patients’ out-of-pocket costs are rising in part due to a ‘freeze’ on Medicare rebates that commenced in 2013 [22]. Primary care professionals often have established longstanding therapeutic relationships with their patient by the time they begin planning for pregnancy or becoming pregnant. In Australia, GPs often serve as the initial point of contact for antenatal care this provides them an early opportunity to screen for alcohol use during preconception and pregnancy, and to provide support and advice as needed.

Australian research among primary healthcare professionals, to inform the development of the FASD – National Awareness Campaign for Pregnancy and Breastfeeding Women [23], outlined a plethora of behaviours and barriers preventing effective intervention by health care professionals around alcohol use among women who are pregnant or planning pregnancy (e.g. lack of knowledge of risks, lack of time / competing priorities, fear of damaging relationship with patient), but also opportunities to address the barriers [24]. Primary care clinicians suggested that if relevant prompts to screen for preconception or antenatal alcohol use were included in clinical software systems, then universal and consistent screening in primary care would be more likely [24]. This finding led the Foundation for Alcohol Research and Education, funded by the Australian Government Department of Health and Aged Care, to commission independent research in 2022 to determine the feasibility of integrating a clinical decision support tool for alcohol screening into general practice clinical software.

The overarching study aimed to increase understanding of: 1) an appropriate and acceptable clinical decision support tool for alcohol screening of patients who are pregnant or planning pregnancy to be used by health care providers in primary heathcare settings in Australia and the circumstances when a prompt would occur; 2) the benefits, barriers and enablers of implementation; 3) the clinical software vendor(s) to target for implementation; and 4) the process, cost and timeframe for development and implementation. Below we detail the findings for the first two aims. Elements of the third and forth aims are briefly included (detailed in an unpublished report to the funder).

Study design

The study design was guided by the need to respond to the questions proposed by the funder as shown in Box 1. The study used a Health Policy and Systems Research (HPSR) approach which draws on social science perspectives and uses a problem rather than method-driven approach to develop ‘real-world’, feasible solutions to support the development and implementation of applied policy and health system change [25, 26]. The study was conceived and conducted across five stages as outlined below, undertaken between November 2022 and May 2023. The research team included two academic GPs, a health data informatician, and two health policy/systems researchers (one a health social scientist, the other a biostatistician / informatician (both with clinical backgrounds) and a public health PhD candidate. Ethics committee approval and informed consent from participants were obtained (see Declarations).

Box 1. Guiding research questions

Overarching research questions (Questions 1 to 4 included in this paper)

1. What are the benefits of integrating a prompt into general practice management software for alcohol screening?

2. What is an appropriate patient criteria to initiate a prompt for alcohol screening for women who are pregnant or planning pregnancy, at the initial appointment and subsequent follow up appointments?

3. What alcohol screening tool would be acceptable to health professionals as a prompt?

4. What are the barriers and enablers to successful implementation?

5. What is the process and timeframe for development and implementation of a prompt in general practice management software?*

6. Who are the priority software vendors to target for implementation in a general practice and Aboriginal Medical Service (AMS) setting?*

7. For those priority software vendors, what is their market share in a general practice and AMS setting in Australia?*

8. What is the indicative cost for development and implementation?*

Questions guiding the literature review (Questions A to C included in this paper)

A. Which patients should be screened for alcohol use when pregnant or when planning a pregnancy?

B. What screening tools for alcohol use during pregnancy have been validated for use in primary care settings, both nationally and internationally?

C. What clinical software management software systems are in use in Australian general practice?

D. What are the enablers of and barriers to integrating clinical decision support tools into existing clinical management software systems?**

* Information provided directly to the funder.

** Findings published elsewhere, see [27]

Stage 1: Understanding the evidence. A rapid literature review was used to establish base knowledge on questions A to D (Box 1); this helped inform Stage 2 data collection and provided context for Stage 3 data analysis. Findings from questions A to C are discussed below. The review methodology is summarised in Box 2. Based on information gathered in response to question B, a prototype screening tool for use in Stage 2 was developed by author LD incorporating an adapted Alcohol Use Disorder Identification Test (AUDIT)-C (consumption subset) for pregnancy screening tool [28] (see Results and Supplement A–Prototype alcohol screening tool). The list of clinical software vendors gathered in response to review question C (Box 1) was used as an invitation register at Stage 2.

Box 2. Literature review methodology

Search strategy for questions A and B:

A. Which patients should be screened for alcohol use when pregnant or when planning a pregnancy?

B. What screening tools for alcohol use during pregnancy have been validated for use in primary care settings, both nationally and internationally?

Manual searches of MEDLINE (Web of Science: 1900–2022) and Scopus (1996–2022) databases were conducted by LD in December 2022. The search was limited to English-language studies published up to December 2022. The inclusion of ‘primary care’ search terms were too restrictive, as many of the studies and papers discuss use of the tools in antenatal care settings without specifying whether these are primary or secondary care settings, and many of the screening tools identified do not have validation studies specifically for primary care settings. We therefore included the broader term of healthcare to allow for inclusion of literature about alcohol screening in any care setting where antenatal care was being delivered.

1431 articles were captured in the search. We also captured papers with an expanded search by using snowballing from reference lists of key articles, and purposive searches for key guidelines. Of all evidence captured and after review of data, 58 relevant articles, guidelines and reports were used to inform review question A and B.

Example search terms:

alcohol OR ethanol OR drink* (All Fields) AND pregnan* OR antenatal OR prenatal (All Fields) AND healthcare OR primary AND care OR general AND practi* OR gp OR doctor OR physician OR family AND physician (All Fields) AND identif* OR detect* OR screen* (All Fields)

Stage 2: Understanding experience. Key stakeholders were purposively sought to canvas knowledge and opinion to answer the eight research questions (Box 1). The identified stakeholders were representatives from vendors / creators of clinical software packages used in Australian general practice (hereafter referred to as vendors), GPs and practice nurses (including from Aboriginal Medical Services), representatives from professional associations representing primary health care providers (hereafter referred to as professional association representatives), and relevant researchers.

Guided by the research questions, two interview question guides were created, one for vendors, the second for all other interviewees (see Supplement B). Interview questions and screenshots of the mock software-embedded alcohol screening prototype (developed in Stage 1) were circulated prior to the interviews.

A mix of recruitment methods were used. Invitations were sent to vendor organisations identified at Stage 1 (see Table 2), professional associations representing clinicians in general practice, and researchers with relevant areas of expertise. Representatives from the Royal Australian College of General Practitioners (RACGP) Specific Interest Group in Antenatal and Postnatal Care, the Expert Committee – Practice Technology and Management, and GPs working in Aboriginal Community Controlled Health Organisations were specifically approached by email. Follow-up emails and phone calls were used to prompt non-responders. GP and primary care nurse participants were also recruited including through snowball sampling. Information about the study with a QR code linking to a recruitment information page was also included on a poster presentation at the RACGP GP22 conference in late November 2022.

Semi-structured virtual interviews were conducted between February and April 2023 using Microsoft Teams. All interviews (n = 23) were audio-recorded, 22 were video recorded, and all were transcribed verbatim. Interviews with 10 GPs and two practice nurses were undertaken by LD, the other 11 interviews were conducted by RC and CC. Interview length ranged from 19 to 62 minutes (average 44 minutes).

Stage 3: Data analysis and synthesis. Interview transcripts were uploaded into QSR NVivo 12 Plus [29] and thematically analysed, grouped by the questions asked. We also reviewed informants’ data for emergent themes [30]. In keeping with the analysis, our results are grouped to respond directly to the research questions. Guided by the HPSR approach and informed by our literature review and interview findings, we developed a draft set of recommendations around the design of the proposed screening tool, the processes for its development, supplementary funding, and guideline reform. An initial set of ten overarching recommendations (comprising 16 base recommendations) were ‘sense-tested’ at Stage 4.

Stage 4: Sense-testing recommendations. We created an online questionnaire (open for anonymous feedback from 27th April to 22nd May 2023), hosted on the University of Melbourne’s instance of the Qualtrics platform [31] to enable rapid capture of ‘sense-testing’ of the draft recommendations developed at Stage 3, via a five-point Likert scale (Strongly Agree, Agree, Neutral, Disagree, Strongly Disagree) and optional long answer comments (see Supplement C). Emailed invitations and a reminder to complete the questionnaire were sent to the vendors contacted at Stage 2 (including those who declined to be interviewed). Additionally, an invitation with survey link was widely distributed via the RACGP Research Noticeboard (publicly accessible), GPs Downunder Facebook page (a closed Facebook community of around 5,800 GPs in Australia and New Zealand), the Victorian primary care practice-based Research and Education Network (964 emails opened by 447 recipients - www.gp.unimelb.edu.au/vicren). The Questionnaire was commenced by 32 eligible people and completed by 22. A total of 54 free-text comments were left by 12 of the 22 respondents. No respondent left a comment for every recommendation.

Stage 5: Final analysis and reporting. Feedback from Stage 4 was reviewed, recommendations finalised and a confidential report to the funder was submitted responding to all questions in Box 1.

Literature review

Key findings from the literature review (Stage 1) are as follows:

A. Which patients should be screened for alcohol use when pregnant or when planning a pregnancy?

Predictive factors for alcohol use during pregnancy in Australia are alcohol consumption prior to pregnancy and increasing maternal age, whereas awareness of the NHMRC Guidelines’ recommendation not to drink in pregnancy is associated with a lower likelihood of alcohol use in pregnancy [4]. As detailed in the Background, general practice and obstetric care guidelines in Australia and internationally are in broad consensus that all pregnant women should be advised of the risks of prenatal alcohol exposure and that the safest option is not to drink during pregnancy [12–20].

Timing and context of discussions around alcohol use prior to pregnancy presents challenges to clinicians. Around half of all pregnancies in Australia are unplanned, and around 55% of pregnant women report drinking alcohol prior to pregnancy recognition [11]. This suggests the importance of conversations about alcohol use for patients of reproductive age [10] and several national and international guidelines recommend this [18, 32–34]. A challenge of meeting this recommendation is that a minority of Australian women present to their GPs specifically for preconception care, unless they are accessing assisted fertility [35, 36].

B. What screening tools for alcohol use during pregnancy have been validated for use in primary care settings, both nationally and internationally?

We found ten tools that were used to screen for prenatal alcohol exposure in a variety of Australian and international health care settings, and we compared their features to determine if they were appropriate for use in Australian general practice. The features of a prenatal alcohol screening tool that make it appropriate for the Australian general practice context include that it be:

sufficiently brief to be used in a typical GP consultation of 10–15 minutes;
sufficiently sensitive to detect low or infrequent levels of alcohol use, including ‘special occasion’ drinking;
acceptable to primary care clinicians and patients alike.

It is also important that the tool has been validated in an Australian clinical practice context. Four of the tools identified had features suitable for the Australian general practice context. The remaining had characteristics that would render them less appropriate or practical. The tools are summarised in Table 1.

The most familiar in the Australian general practice setting is the Alcohol Use Disorder Identification Test (AUDIT) and its derivatives the AUDIT-C (AUDIT-consumption subset) and the AUDIT-C for pregnancy [15, 37–39]. Other tools that were identified as having potential value in the Australian setting are the Grog Survey App [40–42] and ASSIST [43], although none are without limitations.

Of the tools that we identified, the AUDIT-C for pregnancy [28] best fulfils the Australian general practice use criteria; notwithstanding the minor critique that the use of ‘standard drinks’ requires careful explanation to patients, and that there may be a need for an additional question to capture ‘special occasion drinking’. The AUDIT-C is speedy to administer and already widely used and validated in the Australian general practice context including in Aboriginal health settings. The differences between the tools are described in Table 1.

Table 1

Alcohol use screening tools for health care settings
	Tool	Comments
1a	AUDIT	A 10-item screening questionnaire Alcohol Use Disorder Identification Test (AUDIT) developed by the World Health Organization. Includes questions about patterns of alcohol consumption, as well as about behavioural and attitudinal factors that suggest higher risk alcohol use and dependence. Has lower sensitivity for stop-start drinking patterns. [44]
1b	AUDIT-C	An abbreviated form of the original AUDIT, which includes just the subset of 3 questions that enquires about the frequency and quantity of alcohol use. Widely used and validated in the Australian context and incorporated into a range of general practice clinical management systems in Australia. Validated for use in Aboriginal and Torres Strait Islander health settings. [38] When used in Aboriginal health settings, assistance often required to convert non-standard measures of alcohol intake into standard drinks. [41, 45]
1c	AUDIT-C for pregnancy	Uses the same three item questionnaire as the AUDIT-C, but asks specifically about alcohol use in pregnancy, and has variable cut-offs for different risk thresholds to reflect that any level of alcohol consumption in pregnancy confers some risk. [28] May fail to identify women who limit their drinking during pregnancy to ‘special occasions’, suggesting that an additional supplementary question may be required. [4]
2	T-ACE	A 4-item alcohol screening tool, the first developed and validated specifically for use in obstetric settings (United States). Asks about alcohol tolerance rather than alcohol use with the rationale that many women may not realise that higher tolerance typically reflects higher levels of consumption and as such would feel less stigma about their response. One of the more widely used tools internationally. May have predictive value in identifying risk for neurobehavioral impacts on the child after prenatal alcohol exposure but the generalisability of this to an Australian setting is limited. [46] Not sensitive for detection of low levels or infrequent alcohol use, as it asks about indicators of dependence and tolerance while not quantifying consumption. [6, 47–50]
3	4-Ps Plus	A 5-item questionnaire that aims to address under-disclosure of alcohol use in pregnancy. Developed and validated specifically for use in antenatal care settings. Asks women about their alcohol use in the month before they found they were pregnant (drinking alcohol prior to pregnancy is a strong predictor of use in pregnancy). Has high sensitivity for detection of alcohol use in pregnancy, while reducing the burden of disclosure on patients. It is quick to use. A significant disadvantage of the 4-Ps Plus tool is that it is copyrighted and requires payment of a licence to use. [51]
4	One Question Screen	A single question tool that may have value in the Australian primary care context: ‘When was your last drink?’ to triage pregnant patients as no risk, low risk and high risk, depending on whether the response is that they are a non-drinker, that their last drink was before pregnancy recognition, or their last drink was after pregnancy recognition. This screening tool was developed and validated in health settings in the Congo. In the event of a positive screen it requires the clinician to ask further questions to quantify alcohol consumption patterns. [52]
5	ASSIST	8 item Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) tool to identify and quantify alcohol and substance use, including in pregnancy [43]. Includes consumption metrics and indicators of dependence and addiction. Estimated to take 5–10 minutes to complete. Given the duration of the average general practitioner (GP) consultation in Australia is 17 minutes, it is not realistic to complete such a screen within the already busy context of an early antenatal consultation. [53]
6	SMAST	A 13-item questionnaire, the Short Michigan Alcoholism Screening Test (SMAST) is designed to detect alcohol use disorders. It explores alcohol use across the lifetime. Abbreviated from the longer Michigan Alcoholism Screening Test (MAST). Used in some antenatal contexts but not developed specifically for use in pregnancy. it is [50, 54, 55]. Poor sensitivity for detecting low levels of alcohol use in pregnancy [6].
7	CAGE	A 4-item questionnaire to assess perception of drinking behaviours, optimised for detecting alcohol use disorders in non-pregnant populations. It does not quantify levels or patterns of consumption and in antenatal settings it is only sensitive to detecting higher levels of alcohol consumption and dependence. [50, 55] One of the earliest alcohol screening tools developed with the intent of removing stigma around disclosure of alcohol use [56]. An adapted version called CAGE-AID is used to screen for other substance use.
8	TWEAK	A 5-item questionnaire that includes questions from T-ACE, MAST and CAGE (two older screening tools). [57, 58] Validated for use in pregnancy. One of the more widely used tools internationally but only likely to detect higher levels of alcohol consumption and dependence, due to its use of higher-risk criteria. [50, 54, 59] Does not quantify levels or patterns of alcohol consumption, so if positive, it requires clinicians to take a further quantitative history.
9	NET	A 3-item questionnaire (Normal drinker, Eye-opener, Tolerance) developed for use in antenatal contexts [60]. It has high sensitivity and specificity for high-risk drinking but is unlikely to detect low and moderate alcohol use. [61]. Has been critiqued as of high risk of “social desirability bias” due to it asking whether the person considers themselves to be a ‘normal drinker’ [50]. Given concerns around the social permissibility of occasional alcohol consumption in pregnancy in Australia, this may lead to further under-recognition of prenatal alcohol use.
10	Grog Survey App	A ‘patient-facing’ instrument rather than a clinician directed screening tool. Validated for use specifically in Aboriginal and Torres Strait Islander health settings. Not validated for use in pregnancy. A culturally sensitive resource that may inform the development of clinician resources. Based on a modified Finnish model, which takes a narrative approach to screening. More time consuming than the AUDIT-C, which limits its appropriateness in many general practice contexts. [40–42]

C. What clinical software management software systems are in use in Australian general practice?

A review including grey literature identified 18 clinical management software systems / electronic medical record (EMR) used in Australian general practice settings, as outlined at Table 2. Some software is locally installed ‘on premises’ on a computer at the general practice or on a server servicing the practice. Cloud-based products have the software hosted on the vendor’s server with businesses accessing it via their web browser and therefore able to access it from any computer with internet access.

Table 2

Clinical software used in Australian general practice
	Software product	Vendor	Comments
1	BP Premier	Best Practice Software P/L	On premises. One of the most use products in Australia. https://bpsoftware.net/
2	Clinic to Cloud	Clinic to Cloud P/L	Cloud-based. https://www.clinictocloud.com/
3	Communicare	Telstra health	On premises. The most widely used product in Aboriginal Medical Services. https://www.communicare.org.au/
4	Direct Control	Connect Direct	Hybrid, desktop and browser apps. https://www.directcontrol.com.au/
5	Genie	Genie Solutions P/L	Vendor reported it is rarely used in general practice, mostly used by specialist medical clinics. https://www.geniesolutionssoftware.com.au/
6	Helix	Telstra Health	Cloud-based product. https://www.medicaldirector.com/products/helix
7	MD Clinical	Telstra Health (MedicalDirector)	On-premises product, one of the most used products in Australia. https://www.medicaldirector.com/
8	Medilink	Medilink	Hybrid. Desktop and cloud. https://www3.medilink.com.au/
9	MediRecords	MediRecords	Cloud-based. https://medirecords.com/
10	Medtech 32 / Evolution	Medtech Global Ltd	Hybrid, on-premises or cloud. Widely used in New Zealand, released in Australian in 2002. https://medtechglobal.com/au/
11	MMEx	ISA Healthcare Solutions	Cloud-based. Used in Aboriginal Medical Services in some parts of Australia and other general practices. https://www.isahealthcare.com/mmex
12	PCIS (Primary Care Information System)	Northern Territory Department of Health	Used in the Northern Territory of Australia in rural and remote health clinics.
13	The Practice	Godbar Software / Frayron P/L	On premise product. https://www.thepracticesoftware.com/
14	PrimaryClinic	Global Health Ltd	Hybrid: has cloud hosted option. https://www.primaryclinic.com.au/global-health/
15	Profile	Intrahealth Australia Ltd	On premises and cloud-based products. https://intrahealth.com/
16	Stat	Stat Health Systems	Includes cloud hosted option. https://stathealth.com.au/
17	Sunrise EMR & PAS	South Australia Health	https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content /sa + health + internet/clinical + resources/clinical + information + systems/
18	Zedmed	Zedmed P/L	On premise or cloud version. https://www.zedmed.com.au/

Participant characteristics

As summarised in Table 3 there were 23 interview participants (Stage 2), and 22 stakeholders who ‘sense-tested’ the draft recommendations (Stage 4). Table three shows their breakdown by stakeholder type and jurisdiction.

Table 3

Participant types and their jurisdictions
Participant type	Interview participants n (%)	‘Sense-testers’ * n (%)
General practice clinical software creator / vendor	7 (30.4)	3 (13.6)
General practitioner	10 (43.5)	15 (68.2)
Practice nurse	3 (13.0)	3 (13.6)
Representative from a primary care-related medical college or association	2 (8.7)	1 (4.6)
Relevant academic	1 (4.4)	N/A
Total	23 (100)	22 (100)
Associated with Aboriginal Medical Services	Unknown	5 (22.7)
Jurisdiction
New South Wales	3 (13.0)	2 (9.1)
Northern Territory	1 (4.4)	Nil
Queensland	1 (4.4)	2 (9.1)
South Australia	0 (0.0)	0 (0.0)
Tasmania	1 (4.4)	0 (0.0)
Victoria	7 (30.4)	12 (54.5)
Western Australia	3 (13.0)	2 (9.1)
National (vendors of clinical software used in general practice)	7 (30.4)	3 (13.6)
Did not say	0 (0.0)	1 (4.6)
Total	23 (100)	22 (100)

* Sense-testers completed a feedback questionnaire where they reviewed the draft recommendations developed as a result of Stages 1 and 2.

Participant perspectives

Benefits of integrating a prompt into general practice management software for alcohol screening

Most general practice clinical software vendors saw benefit in integrating an alcohol screening tool specifically for routine use with pregnant patients. Benefit was described as “self-evident”, “making clinical point-of-care easier”. It was said that most GPs “appreciated… little prompts and reminders…any kind of subtle guidance.”

Not all interviewed GPs routinely screened for alcohol use among pregnant patients. The majority of GPs saw value in having a prompt to conduct alcohol screening for this population, as it could potentially enhance the rates and consistency of screening by GPs who have not yet “bedded down” how to routinely ask patients about alcohol use. The tested language within the tool, and guidance on management depending on screening results, was thought to allow inexperienced and trainee clinicians to feel more confident to conduct screening and “support the use of non-judgemental language”. Having the screening tool embedded, with the expectation that it be used with all pregnant patients, also removed the sense of passing judgement when GPs or nurses could assure patients that they are “routine” questions asked of everyone. An automated visual prompt could also act as a facilitator for initiating challenging conversations with patients:

(By using the formal screening tool) I can be the intermediary or the interface. I can say to patients: ‘Look, this prompt wants me to do this.’ ... Then they don’t feel that it’s necessarily coming from me, who is more their ally and their advocate …. I find it helpful if something pops up and I can go: ‘Look, these are the recommendations. How do you feel about that?’ … I find patients really respond to that sort of informal approach that I can have while engaging with a more formal resource. (GP08)

Appropriate criteria to initiate a prompt for screening

GPs considered that entering a diagnostic code for a current pregnancy was the only feasible criteria for initiating a prompt for alcohol screening in general practice software. Clinician participants agreed that every patient known to be pregnant should be asked about alcohol use: “I think you shouldn’t make any assumptions about anything. You should just ask everybody.”

To guide discussions during pregnancy planning and preconception care, clinicians wanted the tool accessible outside of the automated prompt (visible on the clinical desktop / interface, e.g., drop down menu). GPs considered that the time constraints of general practice consultations and the rarity of patients proactively seeking preconception care, made the inclusion of an automated prompt triggered for pregnancy planning less feasible. GPs were not aware of a diagnostic code or template in general practice clinical software systems to capture ‘Planning Pregnancy’, so first the field would need to be included in the software; however, GPs highlighted that preconception advice tended to be delivered opportunistically in the context of other consultations rather than in a standalone consultation.

GPs identified a range of time points at which they might conduct opportunistic preconception care discussions (e.g. attendances for cervical screening tests and contraceptive advice), at which point they might manually access the pregnancy-related alcohol screening tool. Not all considered that a prompt would be helpful in these contexts, as they tended to judge on a case-by-case basis whether they had time to raise the discussion and to judge how an unprompted conversation about reproductive health might be received by the patient.

GPs identified that the most common timepoint they asked about alcohol use outside of pregnancy was in new patient consultations (i.e., when a patient attends their practice for the first time), and that this timepoint would be the most likely time for them to take a structured alcohol history.

Whether an automated prompt or manually accessed, clinicians were clear that they did not want any potential screening tool to be interruptive of clinical workflow; that is, they did not want to be forced to interact with the prompt to move beyond it. Passive prompts were preferred (e.g. appearing on a banner on the patient’s EMR but not requiring the clinician to interact with it).

Acceptable screening tool

All vendors reported that their clinical software systems incorporated a mechanism to document alcohol use, however, only some included formal screening tools to structure information gathering and risk assessment about alcohol use. None of the vendors were aware of having alcohol screening tools that were specific for pregnancy incorporated into their software.

AUDIT-C was the tool most incorporated into clinical software packages. Its inclusion was reported by some vendors to be relatively new and did not necessarily have prompts to use it: “(the user) basically has to go to the menu to launch it themselves”. Some vendors described other ways to capture data about alcohol, tobacco and drug use or history, e.g. “a couple of text fields and checkboxes”. One vendor described that within their pregnancy module, alcohol screening is one of several items present on a checklist for clinicians, i.e. they provided a place to document that a screen had been conducted, not a mechanism to conduct that screen.

Vendors, mostly, did not have a way to know how often alcohol screening was undertaken by software users–in particular among those presenting as pregnant: “being on premise and having a legacy architecture we don’t get a lot of data about the tools that are used… I couldn’t give you any accurate understand on how often it (AUDIT-C) is actually used”. The exception was with the cloud-based software systems where, without access to patient specific information, the vendor could generate an audit / count of how many times alcohol screening had been interacted with. One cloud-based vendor had a “consented sample” of practices from which they could, for example, check how many times the AUDIT-C assessment was used, which fields were completed and if done during antenatal or postnatal consultations (if pregnancy was recorded or if pregnancy or postnatal care was listed as a reason for visit).

AUDIT-C for pregnancy: All interviewed GPs were familiar with and/or had used the AUDIT-C screening tool, though not all had seen the adapted AUDIT-C for pregnancy [28]. Most felt that if a formal screening instrument was to be used, AUDIT-C for pregnancy was an appropriate screening tool to enquire about and quantify alcohol use (although they differed in opinion as to whether a formal screening tool would work in their own clinical consultations).

A multifunctional tool: There was, however, repeated suggestion that an antenatal clinical decision support tool should not include alcohol alone, but also encompass, at minimum, screening for nicotine and other substance use, and could include other elements of a psychosocial screen including mental health, and domestic and family violence. GPs highlighted that there is a large volume of risk relevant information that needs to be gathered in an early antenatal consult, such that it is impractical to have a separate screening tool to conduct just one facet of screening. For pragmatic reasons, GPs wanted any multifaceted screening tool to have the functionality for clinicians to partially complete, save and return to screen in a future consultation, to allow for clinicians to be able to pivot the focus of their consultations in response to what a patient discloses.

Risk stratification: Clinicians wanted the screening tool to generate scores to risk stratify patients. They emphasised the importance of the tool allowing them to assess how a patient's alcohol risk profile evolves across different timepoints. Additionally, they recommended automating the documentation of these antenatal screening scores and organizing them in a way that facilitates comparisons and tracking of changes in a patient's alcohol risk profile over time.

Repeated prompts

The prompt should repeat with the same patient over time to guard against assumption that alcohol use status pre-pregnancy or in early pregnancy has not changed.

Provide high-level management advice: Based on the risk scores, clinicians wanted the tool to provide high level advice on clinical management. There was concern about a tool providing specific recommendations that they could not feasibly action, or referral pathways that were not available in their area of practice. One GP who worked in a remote area questioned the medicolegal implications of using a screening and risk stratification tool and then not being able to follow the guidance on management, for example, if the advice was to refer to a specialised maternal alcohol and other drug (AOD) service where no such service was available.

Field auto-population: Clinicians wanted the data collected by the tools be able to auto-populate relevant fields in health summaries, electronic referrals and shared maternity care records (with patient consent) and thereby streamline workflow to avoid duplication of effort.

So if it's (screening tool) already embedded into it (clinical software) and also if it has a prompt, then it's more inviting to actually use it… if it auto-populates when we need to do a referral that again is very helpful because it just saves you time. (GP02)

Data accessible for reporting: Having reports of the captured data readily accessible to clinicians to support their quality improvement activities was suggested to increase the utility of the tool, for example, being able to assist in their demonstration of key performance indicators. GPs reported the value of this data in conducting quality improvement activities necessary to maintain accreditation, and some practices also required this to maintain funding.

Associated resources: There were concerns about the feasibility of maintaining referral resources given the constantly changing landscape of services with funding cycles, and hyperlocal referral pathways. Most GPs agreed that having one or two contacts for national or state level would be appropriate – though several GPs highlighted the lack of availability of specialist services, whether due to remote locations of practice or due to perception of long wait lists or other barriers to patient access.

Suitability for Aboriginal and Torres Strait Islander communities: A GP working in a remote Aboriginal community expressed the need to ensure that the tool is not optimised for metropolitan areas of the “southern states”, that through consultation it should reflect the needs of the people in Aboriginal communities:

I think if you were talking about rolling the software out to places that have (Aboriginal) communities, then I would do a big consultation process with Aboriginal communities. Get a council of Elders together to ask them whether they think it's appropriate to ask these questions. And of course, what you might ask in Sydney is going to be different to the Northern Territory. (GP06)

Barriers to implementation

Lack of time and incentive: The greatest barrier to using formal alcohol screening tools cited by GPs was lack of time. Vendors also raised lack of time associated with potential unwillingness to make development of a new screening tool a priority in their already full production and update release cycle schedules.

Insufficient consultation and/or projects lacking clear specifications: A barrier to development of an integrated screening tool was insufficient consultation on requirements and therefore lack of clear specifications at the outset thus requiring much “back and forth” between client and vendor–adding to the problem of lack of time.

Alert fatigue: Mentioned by both vendors and clinicians. Some vendors had policies where they actively limited the number of automated prompts (pop-ups) that a GP would receive. Vendors knew that many GPs actively disabled pop-up alerts, even when they were alerts for items requested by end-users. GPs highlighted that when they experience high volumes of prompts, that each individual alert carries less weight, and leads to desensitisation to alerts even where they may be clinically relevant. “Some people don't even look at the prompts and just push cancel, cancel, cancel.” (GP02) GPs indicated this barrier was less of a concern when prompts were non-interruptive to workflow, i.e. that they would be visible on the screen without requiring the clinician to interact with them to continue their consultation.

Technical barriers: The absence of a suitable trigger for a screening prompt before conception was considered a tricky barrier for incorporation of a pre-conception screening prompt into the software. One vendor described this as a problem that could be overcome “as long as you’ve got business logic, you understand what you’re searching for and understand what the rules are and you can translate that to the system, (then) you can do that.” Many of the barriers raised by clinician interviewees align closely with those we identified in the literature [27].

Assumptions

Some GPs acknowledged that their assumptions can be barriers to screening, with one reporting that their patients had such high health literacy that alcohol use “isn’t an issue”, but then reflecting: “Or it could be that I'm actually not picking up (alcohol use) because I'm not asking.” (GP01)

Clinical judgement and discretion: GPs indicated a range of factors they considered when making judgements about timing of discussions about alcohol use, including cues from the patient about how receptive they might be to the discussion and the perception that use of a formal screening tool will detract from doctor-patient rapport, with rapport-building potentially determining whether the patient will return.

Lack of time: Pregnant patients often booked short consultations to discuss pregnancy not realising that a long consultation is often warranted. GPs highlighted that alcohol use is one amongst many complex and often interlinked factors that contributes to pregnancy health outcomes. “The issue of alcohol is only one tip of an iceberg in how to manage a pregnancy appropriately… there’s so much information that it’s very hard to touch on the important bits and know what to deal with”.

Lack of technical know-how: The issue of the software end-users simply not knowing how to fully use the clinical software and therefore not being able to fully access its features, was raised. It was noted that many GPs do not mark a patient as pregnant within the clinical software (EMR) and so miss out on the benefit of existing clinical decision support “smarts” such as, automated advice on safe prescribing in pregnancy. Should an alcohol screening prompt for pregnant women be triggered by documenting a current pregnancy using a diagnostic code in the clinical software, then GPs who fail to use this feature would not trigger the alerts related to alcohol screening.

Structural and cultural barriers

Inadequate government funding: The lack of time to screen, reported by GPs, is in part driven by limitations in Medicare’s fee-for-service funding model for antenatal care. GPs described the negative impact of the capped value of an antenatal consultation (Medicare item number 16500) which is at a lower rate than a long consultation for a non-pregnant patient. This meant that if delivering comprehensive pregnancy care – which takes time – GPs were forced to decide between accepting a financial penalty or passing the cost of taking additional time onto patients in higher out-of-pocket fees to cover the gap. A further structural disincentive to appropriate screening is that the Medicare item number that specifically remunerates antenatal alcohol screening (Medicare item 16591) as a component of a psychosocial screen can only be claimed after 28-weeks gestation and only once per pregnancy; this does not align with clinical practice guidelines that state alcohol screening should be conducted early and often for every pregnancy. GPs reported that funding disincentives did not change their commitment to delivering high quality antenatal care, but expressed frustration that this care was devalued or made less accessible.

Under-resourced health system: GPs working in locations spanning major metropolitan settings through to remote areas of Australia indicated that they struggled to access specialist care for their patients even when clinically indicated. One GP working in an under-resourced remote community where rates of problem alcohol use were very high described a sense of futility, that gathering data about alcohol use through formal screening is little more than “just ticking boxes” unless there is the resourcing to address the underlying drivers and manage the impacts of alcohol use.

Lack of trust: GPs stressed that the approaches in working with Aboriginal and Torres Strait Islander patients must consider not just linguistic and cultural differences, but the impacts of intergenerational trauma, and the legitimate concern some community members may have that the data gathered by health care professionals may have potential to be used punitively against them, especially with regard to custodial proceedings. This was flagged as a particular barrier by a GP working in the Northern Territory, who emphasised the huge extent to which mandatory reporting laws have broken trust in the confidentiality of health information, and inhibited rates of disclosure of clinically relevant information like alcohol consumption.

Enablers of successful implementation

Vendor funding and clear specifications

Vendors wanted funding and well thought through specifications before being approached to carry out development work to integrate alcohol screening / decision support tool into general practice clinical software; yet some also wanted to be consulted on specification development to ensure “alignment and agreement from industry” and technical feasibility.

Education and training: GPs and PNs suggested key facilitators to use of the screening tool integrated into clinical software was training accompanying the release of software updates. The training should include evidence on why and how using such a tool would make a difference in terms of clinical outcomes for patients, as well as demonstrable improvement in ease of workflow in gathering, documenting, and using health data. GPs emphasised that training usually focused on clinical aspects while technical aspects of using software systems is assumed and as such, there are many clinicians within the primary care workforce with poor digital literacy.

Co-design with end-users

To ensure the tool is practical and enhances clinician workflow rather than adding to workload, with sufficient piloting and testing of the messaging to be used within the decision support tool.

Pre-consultation questionnaires

To screen for alcohol use (and potentially other substances and mental health, etc) were described as an alternative or adjunct to in-consultation screening as a strategy to maximise the value of time-constrained consultations. Some GPs reported using pre-consultation questionnaires for mental health screening in their current practice, and those who were using systems for doing this flagged the value of this in ensuring consultation time can be used as efficiently as possible. “That way we (GPs) can focus on dealing with any issues (arising from the screening) rather than trying to identify them and deal with them in the consultation.” (GP researcher) It was suggested that a ‘third party’ organisation external to the software vendor might develop the screening tool to sit outside of the clinical software, but to, ideally, integrate collated information within the clinical EMR. A barrier to conducting pre-consultation questionnaires is that it requires a mechanism for the patient to record the reason for their visit when they book, to alert the practice to send the relevant questionnaire, and few GPs reported this mechanism in place in their current practice.

Appropriate resourcing

Reform of government funding for GPs (Medicare), to ensure appropriate rebates for longer antenatal consultations, was considered a major enabler to allow time for routine alcohol screening during pregnancy. GPs stressed that funding must provide appropriate resourcing not simply to conduct the screening, but to adequately manage the care needs of the patient if they do disclose a level of alcohol use that requires further treatment. The issue of misalignment of Medicare funding and clinical practice guidelines, where the current funding model does not allow for alcohol screening early and often in pregnancy, was also raised.

Recommendation summary

Based on our literature review and stakeholder interview findings we developed a series of 11 overarching recommendations to guide the design of an antenatal screening tool and the process for its development and integration into existing clinical software systems. An additional recommendation related to reform of GP reimbursement (Medicare Benefits Scheme) to address major barriers highlighted by GPs is included. Most of the recommendations were ‘sense tested’ by stakeholders who were overwhelmingly positive. The recommendations and results of the sense testing are provided at Supplement D.

Funding for this research was prompted as an outcome of a previous study among primary care clinicians that suggested if prompts to screen for preconception and antenatal alcohol use were included in clinical software systems, then universal and consistent screening in primary care would be more likely [24]. Our research supports the idea of integration of such a prompt, and we have found integration is straightforward and feasible, and there are options in how it might be approached. A major theme highlighted by our clinician participants was that while the integration of alcohol screening prompt would be likely to increase screening for antenatal alcohol use in general practice settings (notwithstanding the additional barriers in providing preconception advice), there remain systemic barriers to consistent and universal screening that need to be addressed, such as reform to how the government funds antenatal care and specifically alcohol screening during pregnancy as enabled by GPs through the Medicare Benefits Scheme. With additional funding for primary care promised by Australian state and federal government budgets [62, 63], lobbying for Medicare reform to antenatal consultation rebates is timely.

Our review revealed 18 clinical software packages used in general practice in Australia, two of which hold the majority market share. BP Premier (vendor = Best Practice) and MD Clinical (vendor = MedicalDirector/Telstra Health) are the most used clinical software packages in Australian general practice. In 2019 it was suggested that outside of the two big players “all the smaller market players like Zedmed, Meditech and new players like MediRecords… collectively have somewhere between 12% and 15% of the (GP) market share” [64]. Communicare (vendor = Telstra Health) is used in most of the Aboriginal Community Controlled Healthcare Organisations.

The multiple clinical software packages used in Australian general practice and lack of enforced standards across software platforms [65] means that difference in the software’s underlying architecture will translate to technical differences to the back end of the antenatal screening tools and differences in the user interface. This is a fundamental barrier to the use and re-use of a ‘blueprint’ set of specifications for the development and integration of a clinical decision support tool for alcohol screening of pregnant women across all clinical management software products. Nonetheless, with two general practice software vendors having the majority of the market share, it is feasible to implement a tool that could be used by the majority of general practices in Australia.

We determined that the AUDIT-C for pregnancy [28] met the criteria for a suitable antenatal alcohol screening tool for use in general practice settings and therefore a suitable tool for integration into clinical software, and we found that software vendors and clinicians agreed that this was an acceptable tool. AUDIT-C for pregnancy overcomes the problem common to many screening tools that were developed at a time when the relationship between low levels of prenatal alcohol exposure and alcohol related harms to the foetus were less clear. As such, many other screening tools score with cut-off thresholds that have greater sensitivity for high-risk alcohol use and alcohol use disorders, but poor sensitivity for low level or infrequent alcohol consumption. With improved understanding of the impact of even very low levels of alcohol during pregnancy, many of these tools may fail to identify a significant proportion of patients who are drinking at levels that would be considered low or moderate outside the context of pregnancy. We note, however, the appetite from GPs for a broader screening instrument covering other aspects of antenatal care in addition to just alcohol screening, which would be a limitation if AUDIT-C for pregnancy was incorporated as a standalone tool.

Through consultation with GPs, we have developed a set of design recommendations for ‘wished for’ features for a screening tool integrated into clinical practice software. These include that: the use of the tool be triggered when a GP documents a current pregnancy in the EMR; the tool be readily accessible outside of automated prompting; generated risk scores be informational and incorporated into the relevant data fields without overwriting prior scores to establish longitudinal trends; the tool allows streamlining of data collecting and collating to avoid duplication of effort in clinical tasks (e.g. calculated scores be encoded in such a way that they can auto-populate relevant fields in health summaries, electronic referrals and shared maternity care records (with patient consent)); and the data be accessible to GPs for their own reporting and quality improvement activities. One of the major recommendations from GPs, including the representative from a professional college representing GPs, was that rather than the tool screening for alcohol only, that it be a multifunctional antenatal screening tool incorporating screens for nicotine and other substance use, mental health, domestic and family violence and other information that is important to support a healthy pregnancy. When this recommendation was sense tested, 18 of 19 responding clinicians agreed or strongly agreed with this (see Supplementary material C). If developed as a multifunctional tool, GPs wanted it to have functionality to complete only part of the screen, save progress and return to the screen at another time.

As an adjunct to the integration of a screening tool into general practice clinical software, the idea of using pre-consultation questionnaires was raised as a possible avenue for increasing routine screening of people who are pregnant or planning pregnancy in a way that enables GPs to make better use of their short consultation times with patients and address the results of the screening within the consultation. Such questionnaires could be deployed by organisations that partner with clinical software vendors (e.g., triggered at time of booking when patient states reason for visit) or having patients complete the questionnaire in the GP waiting room (via a smart phone/tablet or paper copy). Some GPs already used this to deploy common mental health screening tools. For alcohol screening, the Grog Survey App [40–42] and ASSIST [43] tools, both deemed too lengthy to use in most GP consultations, provide more information to clinicians and so have potential utility in the pre-consultation questionnaire space. If using organisations that partner with the clinical software vendor to deploy the screening tool(s) used by the general practice, the preferred mechanism was to have the results of screening fed back into the general practice clinical software fields. This is not always possible due to privacy arrangements. Instead, the results may be provided as a PDF supplement that attaches to the patient’s EMR.

Many vendors have already integrated the standard AUDIT-C tool into their general GP software. However, none of them had made it (or any other alcohol screening tool) accessible from their obstetrics and gynaecology modules. Interviewed vendor representatives had varying insights into how long it would take to integrate a tool such as AUDIT-C for pregnancy into their clinical software, from days to over a year. Smaller vendors reported being able to respond to development requests faster than large vendors that described long clinical and governance review processes and already full schedules for updates planned out for the year ahead (updates for on-premises software). The feasibility of enacting changes within some of the ‘smaller’ (lesser market share) clinical software systems is therefore high with their lower cost and shorter timeframes for deployment (especially in cloud-based products); so, targeting a small vendor to help develop, pilot, deploy and evaluate a new screening tool could be worthwhile.

Whether a standalone alcohol screening tool or a multifunctional antenatal tool that incorporates alcohol screening is developed and implemented, the development costs and timeframe for integration between the two, from a vendor’s perspective, may not be far different. Difference lies in the time required to co-design and test (including for cultural appropriateness) a multifunctional/holistic antenatal screening tool.

Strengths and limitations

To our knowledge this study is the first in an Australian context to comprehensively canvas clinician and software vendor views on the integration of a screening tool into clinical practice software, specifically for review of alcohol use during pregnancy. Despite an earlier study concluding that such prompts could be a strong mechanism to increase rates of alcohol screening, [24] when presented with a prototype and asked to think through how they would use it, the barriers and enablers of alcohol screening in general practice, for clinicians and software developers, became more nuanced. Our findings point to the urgent need for health resourcing reform, to enable GPs to have more time with pregnant patients to ensure comprehensive care, including early and regular alcohol screening. The breadth of our recommendations is a strength, but despite wide dissemination of the invitation to ‘sense test’ the recommendations, the stakeholder response rate for sense-testing was poor. This might reflect a lack of concern among primary care clinicians, or the very issue we have highlighted, clinician’s lack of time.

A challenge we have noted, not identified by the interviewed stakeholders, was discussion always centred around pregnant women and did not account for pregnant people who do not identify as women. This is a relevant consideration both from a clinical care and a software perspective. Many of the software systems offer tools and modules in an individual patient’s EMR based on how their sex or gender is recorded in the software (for instance, patients documented as male will not receive prompts for overdue cervical screening tests or have access to obstetric modules). Where digital tools use algorithms like these to determine which prompts will be generated for which patients, there is the potential to reinforce disparities in care delivery for birth parents who do not identify as women. There must be a mechanism in the software for clinicians to access appropriate screening tools for their patients based on their clinical needs rather than their recorded sex or gender.

The integration of a tool for screening for alcohol use among people who are pregnant or planning pregnancy into general practice clinical software is feasible; however, a multifunctional antenatal screening tool, incorporating other psychosocial elements, was considered more useful than a stand-alone alcohol screening tool. Further work is needed with vendors and end-users to develop an acceptable tool that can be widely implemented so to facilitate routine alcohol screening among those who are pregnant or planning pregnancy, attending primary care consultations. The lack of appropriate funding for GPs to conduct preconception and prenatal alcohol screening is a significant barrier to improving rates of screening. A funding scheme that aligns with clinical practice guidelines could support and incentivise GPs to screen for alcohol use early and often during pregnancy.

ASSIST Alcohol, Smoking and Substance Involvement Screening Test

AUDIT-C Alcohol Use Disorder Identification Test - Consumption subset (and AUDIT-C for pregnancy)

BP Best Practice (clinical software package)

CAGE Cut, Annoyed, Guilty, Eye. A 4-item alcohol screening questionnaire

EMR Electronic Medical Record

FARE Foundation for Alcohol Research and Education

FASD Foetal Alcohol Syndrome Disorder

GP General practitioner

HPSR Health Policy and Systems Research

MAST Michigan Alcoholism Screening Test. Designed to detect alcohol use disorders.

MD MedicalDirector (clinical software package)

NET Normal drinker, Eye-opener, Tolerance, alcohol screening test

RACGP Royal Australian College of General Practitioners

SMAST The Short Michigan Alcoholism Screening Test.

Ethics approval and consent to participate

The research was performed in accordance with the relevant guidelines and regulations, e.g. the Australian National Statement on Ethical Conduct in Human Research which is in accordance with the National Health and Medical Research Council Act 1992 and the Declaration of Helsinki. Ethics approval for the study was obtained from The University of Melbourne Human Research Ethics Committee: ID No. 2022-25585-35607-3. The GP interviews were conducted as part of a linked study also approved by The University of Melbourne Human Research Ethics Committee: ID No. 2022-24433-34787-6. All interviewed participants were given plain language information statement and provided written informed consent. The online feedback questionnaire contained a summary of consent and statement that submission of the questionnaire implied consent to participate.

Consent for publication

No individual person’s identifiable information is used in this manuscript. The consent form, however, contained the following statement: “I understand that given the small number of participants involved in the study, it may not be possible to guarantee my anonymity.”

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

DB, RC and CH are part of the HaBIC Research Information Technology Unit (HaBIC R2) unit in The University of Melbourne Department of General Practice and Primary Care; HaBIC R2 works with general practice clinical software vendors around data acquisition and clinical decision support tools.

Funding

This research and the publication fees were funded by FARE (Foundation for Alcohol Research and Education). The research questions guiding the work were outlined in FARE’s August 2022 request for tender. Comments from FARE staff were received in the confidential report upon which this manuscript is based, however, the funder did not play a role in the research design, data collection, analysis, interpretation, report or manuscript writing.

Authors’ contributions

RC, DB, LD, KH contributed to the study design. LD and CH undertook the literature review. CC, LD and RC undertook participant interviews. LD and RC analysed interview data and drafted the report to funder. RC completed the first draft of this manuscript. All authors contributed to and approved the final manuscript.

Acknowledgements

We thank Kitty Novy, Rachel Komen and Cassandra Caddy for their contribution to recruitment, all unnamed interviewees who contributed their time and perspectives, and the following people opted to be named in published results as having contributed to this research: Charmaine Tam (Telstra Health), Chris Pearson (ISA Healthcare Solutions), Jayne Thompson (MediRecords), Gavin Godfrey (Godbar Software), Elaine Cornford (APNA–Australasian Primary Health Care Nurses Association), Nicole Whittal RN, Jo-Anne Manski-Nankervis (Academic GP), Rob Hosking (Chair, Expert Committee - Practice Technology and Management, Royal Australian College of General Practitioners).

Authors’ information

RC – Rachel Canaway is a health social scientist and qualitative researcher with clinical training and expertise in health services, systems and policy research.

LD – Libby Dai is a general practitioner and a research fellow at the University of Melbourne.

CH – Christine Hallinan is a postdoctoral research fellow and biostatistician with a clinical background in Critical Care. She coordinates the Doctor of Medicinal Research Scholar and Honours Degree programs at the University of Melbourne’s Department of General Practice and Primary Care.

KH – Kelsey Hegarty is an academic general practitioner who holds the joint Chair in Family Violence Prevention at the University of Melbourne and the Royal Women's Hospital. She leads the Safer Families Centre for Research Excellence.

CC – Cassandra Caddy is a PhD candidate at the University of Melbourne.

DB – Douglas Boyle is a Professor of Clinical Data Analytics and Director of the Research Information Technology Unit in The University of Melbourne’s Department of General Practice and Primary Care.

Popova S, Charness ME, Burd L, Crawford A, Hoyme HE, Mukherjee RAS, et al. Fetal alcohol spectrum disorders. Nature Reviews Disease Primers. 2023;9(1):11. doi:10.1038/s41572-023-00420-x
Charness ME. Fetal Alcohol Spectrum Disorders: Awareness to Insight in Just 50 Years. Alcohol Res. 2022;42(1):05. doi:10.35946/arcr.v42.1.05
Jones KL, Smith DW. Recognition of the fetal alcohol syndrome in early infancy. Lancet. 1973;302(7836):999-1001. doi:10.1016/s0140-6736(73)91092-1
Tsang TW, Kingsland M, Doherty E, Anderson AE, Tully B, Crooks K, et al. Predictors of alcohol use during pregnancy in Australian women. Drug and Alcohol Review. 2022;41(1):171-81. doi:10.1111/dar.13330
Foundation for Alcohol Research and Education. Research with health professionals to inform the FASD – National Awareness Campaign for Pregnancy and Breastfeeding Women. Canberra: FARE; 2022 [cited 2023 14 June]. Available from: https://fare.org.au/research-with-health-professionals-to-inform-the-fasd-national-awareness-campaign-for-pregnancy-and-breastfeeding-women/.
Chang G, Wilkins-Haug L, Berman S, Goetz MA, Behr H, Hiley A. Alcohol Use and Pregnancy: Improving Identification. 1998.
Anderson AE, Hure AJ, Forder P, Powers JR, Kay-Lambkin FJ, Loxton DJ. Predictors of antenatal alcohol use among Australian women: a prospective cohort study. BJOG. 2013;120(11):1366-74. doi:10.1111/1471-0528.12356
Hutchinson D, Moore EA, Breen C, Burns L, Mattick RP. Alcohol use in pregnancy: prevalence and predictors in the Longitudinal Study of Australian Children. Drug Alcohol Rev. 2013;32(5):475-82. doi:10.1111/dar.12027
Kingsbury AM, Hayatbakhsh R, Gibbons K, Flenady V, Najman JM. Women's frequency of alcohol consumption prior to pregnancy and at their pregnancy-booking visit 2001-2006: A cohort study. Women Birth. 2015;28(2):160-5. doi:10.1016/j.wombi.2014.11.005
McCormack C, Hutchinson D, Burns L, Wilson J, Elliott E, Allsop S, et al. Prenatal Alcohol Consumption Between Conception and Recognition of Pregnancy. Alcohol Clin Exp Res. 2017;41(2):369-78. doi:10.1111/acer.13305
Australian Institute of Health and Welfare. National Drug Strategy Household Survey 2019 2020 14 June 2023 [cited 2023 14 June]:[104 p.]. Available from: https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/contents/summary.
World Health Organization. Guidelines for the identification and management of substance use and substance use disorders in pregnancy. 2014. Report No.: 9789241548731.
American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 496 At-Risk Drinking and Alcohol Dependence: Obstetric and Gynecologic Implications. 2011.
American College of Obstetricians and Gynecologists. Alcohol Abuse and Other Substance Use Disorders: Ethical Issues in Obstetric and Gynecologic Practice. 2020.
Department of Health. Clinical Practice Guidelines: Pregnancy Care 2020 [cited 2023 30 June]. Available from: https://www.health.gov.au/resources/pregnancy-care-guidelines.
National Health Medical Research Council. Australian guidelines to reduce health risks from drinking alcohol. 2020. Report No.: 9781864960716.
Furtwængler NAFF, De Visser RO. Lack of international consensus in low-risk drinking guidelines. Drug and Alcohol Review. 2013;32(1):11-8. doi:10.1111/j.1465-3362.2012.00475.x
Jonsson E, Salmon A, Warren KR. The international charter on prevention of fetal alcohol spectrum disorder. Lancet Glob Health. 2014;2(3):e135-7. doi:10.1016/s2214-109x(13)70173-6
BMA Board of Science. Alcohol and Pregnancy: Preventing and managing fetal alcohol spectrum disorders. British Medical Association; 2016.
Manatū Hauora Ministry of Health. Alcohol and Pregnancy: A practical guide for health professionals. In: Manatū Hauora Ministry of Health, editor. 2010.
Australian Institute of Health and Welfare. Alcohol, tobacco & other drugs in Australia: Impacts of COVID-19 on alcohol and other drug use. 2022.
Angeles MR, Crosland P, Hensher M. Challenges for Medicare and universal health care in Australia since 2000. Medical Journal of Australia. 2023;218(7):322-9. doi:https://doi.org/10.5694/mja2.51844
DoHA. Every Moment Matters – The National Awareness Campaign for Pregnancy and Breastfeeding Women. Canberra: Department of Health and Aged Care Australian Government; 2022 [Available from: https://www.health.gov.au/our-work/every-moment-matters-the-national-awareness-campaign-for-pregnancy-and-breastfeeding-women.
Heartward Strategic. Research with Health Professional to inform the FASD - National Awareness Campagin for Pregnancy and Breastfeeding Women 2021 14 June 2023 [cited 2023 14 June]:[93 p.]. Available from: https://fare.org.au/research-with-health-professionals-to-inform-the-fasd-national-awareness-campaign-for-pregnancy-and-breastfeeding-women/.
Gilson L, editor. Health policy and systems research: a methodology reader. Geneva: Alliance for Health Policy and Systems Research, World Health Organization; 2012.
Robson C. Real world research: a resource for social scientists and practitioner-researchers, 2nd edition. Oxford: Blackwell Publishers Ltd; 2002.
Hallinan CM, Dai L, Canaway R, Hegarty K, Boyle D. The barriers and enablers to the integration of a clinical decision support systems into general practice medical software: A narrative review using a systematic approach. PREPRINT (Research Square). doi:10.21203/rs.3.rs-3350348/v1
FARE. Using the AUDIT-C for assessment of alcohol use in pregnancy: a resource for health professionals. Every Moment Matters, Foundation of Alcohol Research and Education (FARE); n.d. [cited 2023 28 May]. Available from: https://everymomentmatters.org.au/resources/?type=fact-sheet.
QSR International. NVivo Qualitative Data Analysis Software [NVivo 12 Plus]. Melbourne2020.
Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3(2):77-101. doi:10.1191/1478088706qp063oa
Qualtrics Resarch Core. The University of Melbourne; 2023 [cited 2023 22 November]. Available from: https://lms.unimelb.edu.au/learning-technologies/qualtrics.
The Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 9th ed, updated ed. East Melbourne2018.
American Academy of Family Physicians. Preconception care (Position Paper). 2022.
World Health Organization. Global strategy to reduce the harmful use of alcohol. World Health Organization; 2010. Report No.: 9789241599931.
Mazza D, Chapman A, Michie S. Barriers to the implementation of preconception care guidelines as perceived by general practitioners: a qualitative study. BMC health services research. 2013;13:36-. doi:10.1186/1472-6963-13-36
Dorney E, Black KI. Preconception care. Australian Journal of General Practice. 2018;47(7):424-9.
Muggli E, Cook B, O'Leary C, Forster D, Halliday J. Alcohol in pregnancy: What questions should we be asking? Report to the Commonwelath Department of Health and Ageing. Melbourne: Murdoch Childrens Research Institute; 2010.
Conigrave JH, Lee KSK, Haber PS, Vnuk J, Doyle MF, Conigrave KM. More than three times as many Indigenous Australian clients at risk from drinking could be supported if clinicians used AUDIT-C instead of unstructured assessments. Addiction Science & Clinical Practice. 2022;17(1):23. doi:10.1186/s13722-022-00306-5
Demirkol A, Haber P, Conigrave K. Problem drinking: Detection and assessment in general practice. Australian Family Physician. 2011;40:570-4.
Lee KK, Conigrave JH, Al Ansari M, Wilson S, Perry J, Zheng C, et al. Acceptability and feasibility of a computer-based application to help Aboriginal and Torres Strait Islander Australians describe their alcohol consumption. Journal of Ethnicity in Substance Abuse. 2021;20(1):16-33. doi:10.1080/15332640.2019.1579144
Lee KSK, Conigrave JH, Wilson S, Perry J, Callinan S, Room R, et al. Short screening tools for risky drinking in Aboriginal and Torres Strait Islander Australians: modified AUDIT-C and a new approach. Addiction science & clinical practice. 2019;14(1):22-. doi:10.1186/s13722-019-0152-6
Zheng C, Conigrave JH, Conigrave KM, Wilson S, Perry J, Chikritzhs TN, et al. Patterns of drinking in Aboriginal and Torres Strait Islander peoples as self-reported on the Grog Survey App: A representative urban and remote sample. Drug and Alcohol Review. 2022;41(1):114-24. doi:10.1111/dar.13333
Humeniuk R, Henry-Edwards S, Ali R, Poznyak V, V.Montiero MG, World Health Organisation. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): manual for use in primary care. 2010.
Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. AUDIT: the Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care (second edition) 2001 21 December 2023 [cited 2023 21 December]:[39 p.]. Available from: https://www.who.int/publications/i/item/WHO-MSD-MSB-01.6a.
Lee KSK, Conigrave JH, Callinan S, Wilson S, Room R, Perry J, et al. Asking about the last four drinking occasions on a tablet computer as a way to record alcohol consumption in Aboriginal and Torres Strait Islander Australians: a validation. Addiction science & clinical practice. 2019;14(1):15-. doi:10.1186/s13722-019-0148-2
Chiodo LM, Sokol RJ, Delaney-Black V, Janisse J, Hannigan JH. Validity of the T-ACE in pregnancy in predicting child outcome and risk drinking. Alcohol. 2010;44(7-8):595-603. doi:10.1016/j.alcohol.2009.08.009
Sokol RJ, Martier SS, Ager JW. The T-ACE questions: practical prenatal detection of risk-drinking. Am J Obstet Gynecol. 1989;160(4):863-8; discussion 8-70. doi:10.1016/0002-9378(89)90302-5
Chang G. Alcohol-screening instruments for pregnant women. Alcohol Res Health. 2001;25(3):204-9.
Chang G. Screening and brief intervention in prenatal care settings. Alcohol Res Health. 2004;28(2):80-4.
Dozet D, Burd L, Popova S. Screening for Alcohol Use in Pregnancy: a Review of Current Practices and Perspectives. International Journal of Mental Health and Addiction. 2021. doi:10.1007/s11469-021-00655-3
Chasnoff IJ, McGourty RF, Bailey GW, Hutchins E, Lightfoot SO, Pawson LL, et al. The 4P's Plus© screen for substance use in pregnancy: Clinical application and outcomes. Journal of Perinatology. 2005;25(6):368-74. doi:10.1038/sj.jp.7211266
Williams AD, Nkombo Y, Nkodia G, Leonardson G, Burd L. Prenatal alcohol exposure in the Republic of the Congo: Prevalence and screening strategies. Birth Defects Research Part A - Clinical and Molecular Teratology. 2013;97(7):489-96. doi:10.1002/bdra.23127
Royal Australian College of General Practitioners. Health of the Nation 2023 2023 [cited 2023 21 December]:[90 p.]. Available from: https://www.racgp.org.au/general-practice-health-of-the-nation-2023.
Russell M, Martier SS, Sokol RJ, Mudar P, Jacobson S, Jacobson J. Detecting risk drinking during pregnancy: a comparison of four screening questionnaires. Am J Public Health. 1996;86(10):1435-9. doi:10.2105/ajph.86.10.1435
Montag AC. Fetal alcohol-spectrum disorders: Identifying at-risk mothers. International Journal of Women's Health. 2016;8:311-23. doi:10.2147/IJWH.S85403
Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA. 1984;252(14):1905-7. doi:10.1001/jama.252.14.1905
Russell M. New Assessment Tools for Risk Drinking During Pregnancy: T-ACE, TWEAK, and Others. Alcohol Health Res World. 1994;18(1):55-61.
Russell M, Bigler L. Screening for alcohol-related problems in an outpatient obstetric-gynecologic clinic. Am J Obstet Gynecol. 1979;134(1):4-12. doi:10.1016/0002-9378(79)90787-7
Praestegaard C, Kesmodel PS, Kesmodel US. Is TWEAK a valid screening questionnaire to identify alcohol risk drinkers among pregnant women in Denmark? Acta Obstet Gynecol Scand. 2018;97(4):483-90. doi:10.1111/aogs.13314
Bottoms S, Martier S, Sokol R. Refinements in screening for risk drinking in reproductive-aged women: The “NET” results. Alcohol Clin Exp Res. 1989;13(2a):339.
Burns E, Gray R, Smith LA. Brief screening questionnaires to identify problem drinking during pregnancy: a systematic review. Addiction. 2010;105(4):601-14. doi:10.1111/j.1360-0443.2009.02842.x
Australian Government Department of Health and Aged Care. What we're doing about primary care. Canberra: Australian Government; 2023 [cited 2023 16 June]. Available from: https://www.health.gov.au/topics/primary-care/what-we-do.
Victorian Government. Improving access to primary care. Melbourne: Victorian Government; 2023 [cited 2023 16 JUne]. Available from: https://www.budget.vic.gov.au/improving-access-primary-care.
Knibbs J. How much is MedicalDirector worth this time around? Medical Republic [Internet]. 2019 [cited 2023 14 June]. Available from: https://www.medicalrepublic.com.au/much-medicaldirector-worth-time-around/23751#.
RACGP. Practice Technology and Management: Minimum requirements for general practice clinical information systems to improve usability. East Melbourne: Royal Australian College of General Practitioners; 2018.

Competing interest reported. Authors D.B., R.C. and C.H. are part of the HaBIC Research Information Technology Unit (HaBIC R2) unit in The University of Melbourne Department of General Practice and Primary Care; HaBIC R2 works with general practice clinical software vendors around data acquisition and clinical decision support tools.

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The feasibility of integrating an alcohol screening clinical decision support tool into primary care clinical software: A review and Australian key stakeholder study

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Version 1

Abstract

Background

Methods

Study design

Box 1. Guiding research questions

Box 2. Literature review methodology

Results

Literature review

C. What clinical software management software systems are in use in Australian general practice?

Participant characteristics

Participant perspectives

Benefits of integrating a prompt into general practice management software for alcohol screening

Appropriate criteria to initiate a prompt for screening

Acceptable screening tool

Barriers to implementation

Structural and cultural barriers

Enablers of successful implementation

Recommendation summary

Discussion

Strengths and limitations

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1