INCORPORATING SCREENING, BRIEF

INTERVENTION, AND REFERRAL TO TREATMENT

INTO EMERGENCY NURSING WORKFLOW USING
AN EXISTING COMPUTERIZED PHYSICIAN ORDER
ENTRY/CLINICAL DECISION SUPPORT SYSTEM
Authors: Tamara Slain, RN, Sherry Rickard-Aasen, Janice L. Pringle, PhD, Gajanan G. Hegde, PhD,
Jennifer Shang, PhD, William Johnjulio, MD, and Arvind Venkat, MD, Pittsburgh, PA
Introduction: The objective of this study was to evaluate
whether screening, brief intervention, and referral to treatment
(SBIRT) could be incorporated into the emergency nursing
workow using a computerized physician order entry/clinical
decision support system. We report demographic and operational
factors associated with failure to initiate the protocol and revenue
collection from SBIRT.
Methods: We conducted a retrospective, observational cohort
analysis of a protocol adding SBIRT to the emergency nursing
workow of a single, tertiary care urban emergency department
for all adult patient visits in 2012. Emergency nurses prescreened
for unhealthy alcohol or drug use during triage assessment and,
when positive, administered SBIRT during treatment area care, all
documented in the computerized physician order entry/clinical
decision support system. Using multivariable logistic regression,
we report demographic and operational factors associated with
failure to initiate the protocol. From October 2012, we submitted
charges for brief interventions and analyzed collection results.
Results: The inclusion criteria were met for 47,693 visits. Of
these, 39,758 (83.4%) received triage protocol initiation.
Variables associated with decreased odds of protocol initiation
were younger age (odds ratio [OR] for rising age, 1.044; 95%
condence interval [CI], 1.042-1.045), arrival by ambulance (OR,
0.37; 95% CI, 0.35-0.40), and higher triage acuity (OR, 0.08; 95%
CI, 0.07-0.09). Of visits with protocol initiation, 21.4% were
documented as positive for at-risk alcohol and/or drug use.
However, brief interventions were only administered during 971
visits. During the billing period, $3617.53 was collected on
charges of $10,829.15 for 262 completed brief interventions.
Discussion: In this study electronic documentation of adults
with at-risk alcohol and/or drug use was feasible by emergency
nurses, but SBIRT execution and subsequent revenue collection
were challenging.
Key words: SBIRT; Emergency department; Nursing; CPOE;
CDS; Alcohol; Drug
R E S E A R C H
Tamara Slain, Member, Western Pennsylvania Chapter 061, is Nurse
Educator, Department of Emergency Medicine, Allegheny General Hospital,
Allegheny Health Network, Pittsburgh, PA.
Sherry Rickard-Aasen is Training Coordinator, ProgramEvaluation and Research
Unit, University of Pittsburgh School of Pharmacy, Pittsburgh, PA.
Janice L. Pringle is Director, Program Evaluation and Research Unit, University
of Pittsburgh School of Pharmacy, Pittsburgh, PA.
Gajanan G. Hegde is Associate Professor, Katz Graduate School of Business,
University of Pittsburgh, Pittsburgh, PA.
Jennifer Shang is Professor, Katz Graduate School of Business, University of
Pittsburgh, Pittsburgh, PA.
William Johnjulio is System Chair, Department of Family Medicine, Allegheny
Health Network, Pittsburgh, PA.
Arvind Venkat is Vice Chair, Department of Emergency Medicine, Allegheny
General Hospital, Allegheny Health Network, Pittsburgh, PA.
Sherry Rickard-Aasen and Janice L. Pringle received support from the
Substance Abuse and Mental Heal th Services Administration
(T1020263) to provide training and technical assistance to disseminate
SBIRT (screening, brief intervention, and referral to treatment) across
institutions, although this support did not fund this project. They also
received support from the Staunton Farm Foundation, which partially
funded initial investigator training and consultation in the early stage of
program design, although this support did not fund nursing training or
program implementation.
This study was presented in abstract form at the American College of Emergency
Physicians Scientic Assembly Research Forum, October 15, 2013, Seattle, WA.
For correspondence, write: Arvind Venkat, MD, Department of Emergency
Medicine, Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA
15212; E-mail: avenkat@wpahs.org.
J Emerg Nurs .
0099-1767/$36.00
Copyright 2013 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
http://dx.doi.org/10.1016/j.jen.2013.10.007
WWW.JENONLINE.ORG 1
T
he Centers for Disease Control and Prevention
estimates that 80,000 deaths per year are attribu-
table to excessive alcohol use.
1
In 2011 the
Substance Abuse and Mental Health Services Administra-
tion National Survey on Drug Use and Health reported
that 22.5 million Americans had used an illicit drug in the
month before the survey and that 20.6 million individuals
could be classied with substance dependency or abuse
disorders.
2
For many of these individuals, their entrance to
the health care system is through the emergency depart-
ment. As of 2006, 1.2 million ED visits in the United
States were the result of excessive alcohol use.
3
Between
2004 and 2010, there was a 94% increase in the number of
ED visits related to illicit drug use, reaching an estimated 5
million visits.
4
To address the public health and economic burdens
that result from alcohol and drug misuse, screening, brief
intervention, and referral to treatment (SBIRT) protocols
have been implemented and shown to be effective in the
ED setting.
58
However, these trials have largely been
dependent on sustained external grant funding and
additional personnel placed into the normal workow
of emergency departments to perform and maintain
SBIRT protocols. As a result, the translation of
knowledge on SBIRT from research trials to day-to-day
operational utilization has been rightly identied as a
barrier to the wider dissemination of this important
public health practice in emergency departments across
the United States.
9
The hypotheses of this study were that SBIRT could be
embedded into the normal workow of emergency nurses
assisted by the use of a computerized physician order entry
(CPOE)/clinical decision support (CDS) system and that
demographic and logistical barriers to protocol initiation
could be identied. A secondary objective of this trial was to
report the revenue generated by this activity through billing
of payer sources as a measure of its sustainability in a non
externally funded environment.
Methods
We conducted a retrospective, observational cohort
analysis of a protocol incorporating SBIRT into the
normal emergency nursing workow of a single, tertiary
care urban emergency department with an annual census
of approximately 50,000 visits from January 1 to
December 31, 2012. All arriving ED patients aged 18
years or older met the inclusion criteria for protocol
initiation. This trial was approved by the institutional
review board of our center.
PARTICIPANTS AND SBIRT PROTOCOL
IMPLEMENTATION
Beginning in 2009, at quarterly scheduled emergency nurse
in-service days, the study investigators trained all emergency
registered and licensed practical nurses on the use of the
Alcohol, Smoking and Substance Involvement Screening
Test (ASSIST) and the motivational interviewing skills
needed to conduct brief interventions.
10
The training
method consisted of lectures and demonstrations by the
investigators. During this training, the emergency nurses
were shown how to administer the ASSIST, to calculate the
resulting ASSIST score, to determine the appropriate type
of intervention based on that score, and where appropriate,
to facilitate a referral to treatment or recovery support
services. Throughout 2011, training was repeated for newly
hired nurses and reinforced with existing staff. By the end of
2011, all emergency nurses had completed 3 rounds of
training lasting approximately 2 hours for each session.
In 2011, in discussion with the emergency nurses,
social workers, and medical staff, we developed an SBIRT
protocol to use for all adult patients arriving to the
emergency department (aged 18 years). The protocol
consisted of a 3-part prescreening questionnaire, modied
from the National Institute on Alcohol Abuse and
Alcoholisms maximum drinking limits for men and
women
11
and the National Institute on Drug Abuses
Quick Screen,
12
that would be incorporated into the
standard social history obtained at triage. The 3 questions
were as follows:
1. In the past year, have you had more than 14 alcohol
beverages in 1 week for men or more than 7 alcohol
beverages in 1 week for women?
2. Have you ever accidently overdosed?
3. Have you used any drugs in the past year? (If the
patient answered yes, choices in the electronic note
for nursing documentation were only indicated as
positive for drugs that were not prescribed to the
patient or used for reasons or in dosages other than as
prescribed.)
For patients who answered yes to any of these questions
or if, on emergency nursing assessment at triage, it was clear
that the patient had drunk alcohol to excess or unin-
tentionally overdosed on a drug (eg, the patient arrived after
responding to naloxone for a respiratory arrest) and in cases
in which the patient could not respond to the prescreen
questions, the appropriate prescreen question would be
marked as positive at triage, and the full ASSIST would be
administered during ED treatment. If the ASSIST was
positive (4 for drugs or overdose, 11 for alcohol), then
RESEARCH/Slain et al
2 JOURNAL OF EMERGENCY NURSING
the protocol called for a brief intervention by the treatment
nurse at an appropriate point in the patients ED course.
The brief intervention consisted of motivational interview-
ing techniques to allow the identication of the stage of
change that the patient was in and to respond accordingly.
13
A referral to treatment was offered if the ASSIST was 27 or
greater. For ambulatory patients, the prescreen triage
questions were asked by the dedicated triage emergency
nurse and documented in the triage room of the waiting
area, with the full ASSIST administered by the treating
emergency nurse when the patient was moved into a
treatment room. For patients arriving by ambulance and
placed directly into a treatment room, the treatment
emergency nurse asked the prescreen questions and
administered the ASSIST when appropriate.
In 2011 an electronic ED triage note was added to our
centers CPOE/CDS system (Sunrise; Allscripts, Chicago,
IL). The note was structured so that initial documentation
would include the chief complaint, history of present illness,
and vital signs (quick triage), whereas the medical history,
medications, allergies, and social history, including the
prescreen questionnaire, could be completed by the triaging
emergency nurse separately during the patients initial
evaluation process. We also created an electronic note as
part of the standard nursing assessment for the treatment
emergency nurse to document the completion of the
ASSIST with automated calculation of the score. The note
also served as the means of documenting completion of the
brief intervention and referral to treatment, as appropriate.
The CPOE/CDS system was structured so that when the
prescreen questionnaire was positive, an indicator would
appear on the ED tracking board for the treatment
emergency nurse to execute the ASSIST. It was estimated
by us that prescreen questionnaire completion would take a
maximum of 2 minutes; ASSIST completion, 10 minutes;
and brief intervention, 15 minutes. Beginning on January 1,
2012, the previously described SBIRT protocol was in effect
for all adult patients arriving to our emergency department.
At emergency nursing in-service days, we continued to
emphasize that SBIRT should be considered a standard part
of the emergency departments workow.
OUTCOME MEASURES AND DATA ANALYSIS
In 2013 we downloaded data from the electronic medical
record system at our center on all adult ED visits (aged 18
years) for the study period. The data collected included
demographic variables (age, sex, race, insurance status [self-
pay, Medicare, Medicaid, commercial, or other], and
initial triage acuity [Emergency Severity Index]) and
operational variables (mode [ambulatory or ambulance]
and time [7 AM2:59 PM, 3 PM10:59 PM, or 11 PM6:59 AM]
of patient arrival and daily EDcensus [as a marker of volume
of activity]) (Table 1). These variables were chosen by us as
those that were likely to be associated with failure to initiate
the protocol based on previous experience with incorporat-
ing inuenza vaccination into nursing workow in our
emergency department as a public health intervention.
14
We
also downloaded, based on the nursing documentation at
triage and during treatment, whether the protocol was
initiated (prescreen questionnaire completed) and whether
SBIRT occurred where appropriate.
To analyze whether the previously mentioned demo-
graphic and operational variables were associated with
failure to initiate the protocol, we used multivariable logistic
regression, reporting odds ratios (ORs) with 95% con-
dence intervals (CIs), as well as Wald statistics, with the unit
of study being the visit, rather than the patient, level. Wald
statistics were used to show the relative weight of
independent variables within the derived multivariable
logistic regression model for protocol initiation given the
number of included visits relative to the number of
independent variables in this analysis (Table 2). Model
strength is reported by use of the Nagelkerke R
2
test.
15
Beginning in October 2012, our center began
submitting bills for brief interventions to the payer source
of discharged patients receiving this service. This was the
time at which the nance department of our center
established the necessary procedure and billing codes with
payers for brief interventions. Patients who had no
insurance (self-pay) or were admitted to the hospital, and
thus were billed by use of a diagnosis-related group, did not
receive this itemized bill. We report the revenue received for
these charges, classied as a commercial, Medicare or
Medicaid, or other insurance (eg, workers compensation or
automobile insurance) source for bills submitted for brief
interventions that took place from October 1, 2012.
Results
Table 1 shows the characteristics of included visits (all adult
ED visits during the study period), categorized by overall
visits, visits with prescreen questionnaire completion, and
visits with brief intervention completion. The inclusion
criteria were met for 47,693 visits by 31,525 patients (mean
age, 48.2 years; 48.4% men; 65.9% white and 29.8%
African American). Of the eligible visits, 39,758 (83.4%)
had triage protocol initiation based on prescreen question-
naire documentation. Of those ED visits with prescreen
completion, 8510 (21.4%) were positive for evidence of
at-risk alcohol or drug use and/or behavior (5841 [14.7%]
Slain et al/RESEARCH
WWW.JENONLINE.ORG 3
positive for alcohol, 1499 [3.8%] positive for drugs, 1113
[2.8%] positive for alcohol and drugs, and 57 [0.1%] for
accidental overdose). However, only 971 visits (2% of all
visits) had documented brief interventions after recorded
ASSIST completion, with even more sporadic reporting of
referral to treatment, a much lower rate than that reported
in previous studies on SBIRT in the emergency
department using dedicated personnel or external grant
funding.
58
No brief intervention was documented in 251
additional visits (0.53% of all visits, 20.5% of potential
brief intervention visits) despite the protocol indicating,
based on positive prescreening and ASSIST scores, that
this should have taken place.
Table 2 shows the multivariable logistic regression
model for the association of the selected demographic and
operational variables with protocol initiation (Nagelkerke
R
2
= 0.542). The demographic and operational variables
most signicantly associated and with the greatest variable
weight with decreased odds of protocol initiation were
decreasing age (OR for rising age association with
protocol initiation, 1.044; 95% CI, 1.042-1.045; Wald,
2906.2), higher initial triage acuity (Emergency Severity
Index level 1 or 2) (OR, 0.08; 95% CI, 0.07-0.09; Wald,
2585.5), and arrival by ambulance (OR, 0.37; 95% CI,
0.35-0.40; Wald, 863.4).
Table 3 shows the revenue generation from brief
interventions for bills submitted from October 1, 2012. A
total of $3617.53 was collected on $10,829.15 charged
(33.4% collection rate) from 262 visits with itemized billing
for brief interventions in insured discharged patients.
The collection rate was highest from commercial insurance
(59.5%). In contrast, the collection rate from Medicare
TABLE 1
Study visit characteristics, January 1 to December 31, 2012
Variable All adult
ED visits
(N = 47,693)
Visits with performance
of prescreen
questionnaire (n = 39,758)
Visits with
performance
of brief intervention (n = 971)
Age (mean; interquartile range) (y) 48.2; 31 47.9; 30 41.7; 24
Sex (% male) 48.4 47.3 65.7
Race (%)
White 65.9 65.2 57.0
African American 29.8 31.7 40.2
Other 4.3 3.1 2.8
Insurance status (%)
Self-pay 15.2 15.2 26.9
Medicare 12.3 12.2 6.9
Medicaid 25.9 27.0 37.2
Commercial 44.0 43.3 27.1
Other/unknown 2.6 2.3 1.9
Initial triage severity (%)
Emergency Severity Index level 1 or 2 7.1 3.2 2.2
Emergency Severity Index level 3 57.1 60.7 62.0
Emergency Severity Index level 4 or 5 31.0 33.8 33.1
Unknown 4.8 2.3 2.7
Mode of patient arrival (% ambulatory) 59.8 64.4 53.2
Time of patient arrival (%)
7 AM2:59 PM 38.5 39.8 42.6
3 PM10:59 PM 42.4 41.3 33.4
11 PM6:59 AM 19.1 18.9 24.0
Daily ED census (mean; interquartile range) 143.4; 21 143.1; 21 140.8; 23
Visits resulting in admission (% yes) 34.6 30.4 23.7
RESEARCH/Slain et al
4 JOURNAL OF EMERGENCY NURSING
was 26.7%, and from Medicaid, it was 9.4%. As shown in
Table 3, given that most billable (nonself-pay)
visits involved Medicaid as the payer source, the low
rate of reimbursement impacted the overall success in
revenue collection.
Discussion
To our knowledge, this is the rst report on the integration
of SBIRT into the normal workow of emergency nursing
staff using an existing CPOE/CDS system that extended
beyond the initial prescreen process and was not dependent
on external grant funding or dedicated personnel for
execution of SBIRT. One recently published study did
show the feasibility of incorporating prescreening into the
triage process but relied on both external funding and extra
personnel for SBIRT execution.
15
The emphasis in our
protocol on relying on existing resources and personnel was
meant to determine whether a sustainable effort for SBIRT
could be added to the normal emergency nursing workow
in a manner that might be translatable to the vast majority
of centers that have neither external funding nor extra
personnel for this purpose.
9
To integrate a public health intervention such as
SBIRT into the chaotic environment of the emergency
department, the rst nding from the data in this study
is that the use of CPOE and CDS can assist in the
documentation of at-risk alcohol and drug use/behavior.
These systems allowed the necessary inclusion question-
naires to be added to the standard triage instrument,
facilitating the rapid documentation and transfer of
information on at-risk alcohol and drug use/behavior
seamlessly to the treatment nurse, who could, hopefully,
then complete the protocol. With an 83.4% rate of
protocol initiation and a documented 21.4% rate of at-risk
alcohol- or drug-related use/behavior (similar to previous
studies on SBIRT in the emergency department
58,15
), this
investigation does show that, at a minimum, it is feasible to
train emergency nurses to recognize and electronically
document the presence of a patient population with
problematic alcohol and drug use.
TABLE 2
Multivariable logistic regression model evaluating odds ratios for initiation of protocol by documentation of
performance of prescreen questionnaire
Variable Reference variable Wald Odds ratio 95% condence interval
Lower limit Upper limit
Age 2906.2
a
1.044 1.042 1.045
Sex
Female Male 19.3 0.89 0.85 0.94
Race
Minority (African American, other minority) White 25.9 0.86 0.82 0.91
Insurance status
Medicare Self-pay 124.3 0.52 0.46 0.58
Medicaid 136.3 0.63 0.58 0.68
Commercial/other insurance 125.6 0.63 0.58 0.68
Initial patient triage acuity
Emergency Severity Index levels 1 and 2 Emergency Severity
Index level 3
2585.5
a
0.08 0.075 0.09
Emergency Severity Index levels 4 and 5 36.3 0.84 0.79 0.89
Mode of patient arrival
Ambulance Ambulatory 863.4
a
0.37 0.35 0.40
Time of patient arrival
7 AM2:59 PM 11 PM6:59 AM 7.96 0.90 0.84 0.97
3 PM10:59 PM 112.6 0.68 0.64 0.73
Daily ED census 276.7 1.006 1.005 1.007
a
Signicant Wald statistic for contribution to logistic regression model.
Slain et al/RESEARCH
WWW.JENONLINE.ORG 5
The ndings that arrival by ambulance, higher triage
acuity, and younger patients were signicantly associated
with failure to initiate the protocol indicate that asking the
treatment emergency nurse, as opposed to a dedicated triage
emergency nurse, to perform this task may be too high a
burden. As borne out in this study, the combination of
signicant illness (higher triage acuity) and arrival by
ambulance likely identies a population whose requirement
for acute therapy makes it difcult for a treatment
emergency nurse to also initiate a public health interven-
tion. It is also possible that the documentation system used
at our center, which splits the triage note into 2 parts, is too
much of a burden for a busy treatment emergency nurse in
contrast to a dedicated triage emergency nurse for
ambulatory patients who does not have other clinical
responsibilities.
The need for simplication of the process is also borne
out by the low prevalence of individuals who received brief
interventions. Previous ED studies suggest that we should
have seen a much higher level of individuals receiving brief
interventions for evidence of at-risk alcohol and drug abuse
consumption and behaviors.
58
In considering future
efforts to integrate SBIRT into the nursing workow in
the emergency department using CPOE/CDS systems,
there is an obvious need to construct a mechanism for
ongoing quality assurance both in the area of emergency
nursing documentation and in the area of protocol
execution. Simplication of our processes, perhaps to
move straight from a positive response on the prescreen
questionnaire to a brief intervention without an ASSIST
score calculation, should be evaluated given the constraints
of the ED environment.
To our knowledge, this is the rst study to report the
revenue generated from SBIRT based on billing and
collection. Given the low overall collection rate of 33.4%,
it is clear that the revenue potential from SBIRT continues
to be a work-in-progress. Why there was such a discrepancy
among payer sources with regard to reimbursement for brief
interventions is open to speculation. Some possibilities
include the value placed on this service by various payers
and the particular circumstances of how services at our
center are contracted for with payers in this area.
What is clear is that to realistically incorporate this
public health intervention into day-to-day clinical practice,
there has to be a revenue source that can support continued
training of staff and quality assurance and show both ED
staff and hospital administrators that there is a return on
investment for this effort. Although cost-effectiveness data
suggest that SBIRT can reduce at-risk behavior, which may
lower future health care resource utilization,
9
in the current
low-margin health care reimbursement environment, this
calculation may not be enough to incentivize its incorpo-
ration into general ED practice. It is a valid consideration
that emergency departments, in the context of their many
other clinical obligations, weigh in a cautious manner
whether SBIRT is a worthwhile intervention unless there is
some likelihood of tangible reimbursement. Given previ-
ously cited evidence of the effectiveness of SBIRT in
reducing high-risk behaviors in patients with evidence of
alcohol and drug misuse,
58
it is hoped that the data from
this study may show payer sources that incorporating
SBIRT into ED care is deserving of reimbursement on a
consistent basis.
Limitations
As a single-center study, the operational experience
discussed in this report may not be applicable in all its
details to other emergency departments. For example, the
use of the CPOE/CDS system and the process of triage and
treatment might not be similarly structured at other centers.
In not implementing a quality-assurance program during
our study, we possibly missed opportunities to improve the
execution and effectiveness of this emergency nursing
based SBIRT protocol. However, our goal was to observe,
TABLE 3
Revenue analysis for brief interventions in discharged ED patients with payer source
Type of insurance No. of ED visits
in category
Amount
billed ($)
Amount
collected ($)
% Collected on
billed amount
Medicare 33 1507.29 403.04 26.7
Medicaid 149 4656.00 438.96 9.4
Commercial 71 4665.86 2775.53 59.5
Other (workers compensation, automobile insurance) 9 0 0 0
Total 262 10,829.15 3617.53 33.4
RESEARCH/Slain et al
6 JOURNAL OF EMERGENCY NURSING
rather than intervene, in the execution of this protocol as a
means of determining where its limitations might lie after
initial training. Finally, the revenue analysis in this study
may not translate to other centers given the high variability
of payer sources and contracts that exist.
Implications for Emergency Nurses
The analysis of the implementation of the protocol at our
center points to a fundamental lesson that should be
considered if this important public health intervention is to
be widely disseminated in the high-impact venue of the
emergency department through emergency nurses. Our
results suggest that in attempting to incorporate SBIRT into
the normal emergency nursing workow, there is a
distinction that needs to be made between the identication
of at-risk patients who should receive SBIRT (prescreening)
and the actual execution of SBIRT by emergency nurses
who have other clinical responsibilities. Two potential
solutions that deserve further investigation are either to
simplify the triage process so that critical information can be
more quickly documented, including that in the prescreen
questionnaire, or to program the CPOE/CDS system so
that the next step in the patients care cannot be initiated
until the full triage note is completed. In considering our
experience as emergency physicians and nurses in a center
where other public health interventions (inuenza vaccina-
tion) have been incorporated into the normal workow,
studies to simplify the process and documentation of
SBIRT for use in a high-acuity and rapidpatient turnover
environment would have the highest likelihood of wider
impact and dissemination.
14
Given the current difculty with revenue generation
from SBIRT shown in this study, simplication of
documentation and effort may also allow for an improved
cost-benet calculation by administrators in determining
whether to pursue such a program in the emergency
department. Another possible means to improve revenue
and/or cost-benet calculations would be to evaluate
whether the SBIRT model can be applied to evaluating
other difcult situations simultaneously. Examples might
include intimate partner violence screening and child abuse
screening.
Conclusions
This trial indicates that it is feasible for emergency nurses to
identify and electronically document the presence of at-risk
alcohol and drug use/behavior in arriving adult ED patients.
However, SBIRT execution by treatment emergency nurses
was not comparable with previously reported studies on this
subject that used additional dedicated personnel or external
funding support. The variables most associated with failure
to properly initiate the protocol were younger age, higher
acuity, and arrival by ambulance. Revenue collection for
brief interventions remains challenging. Future studies to
rene incorporation of SBIRT into emergency nursing
workow should focus on simplifying the identication of
candidate patients and the electronic documentation
required for quality assurance and billing for this public
health intervention.
Acknowledgment
The authors thank Larry Gentilello, MD, for his critical review of the
manuscript.
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