Unhealthy Drinking Behavior and the ATTAIN Solution: Web-based Automated Alcohol Misuse Interventions


Jennifer Chevinsky, MD, MPH1; Emma Fredua, MPH, CHES2; Ebonie M Vazquez, MD2; Mohamed H Ismail, MD, DrPH2

Perm J 2021;25:20.141

E-pub: 03/17/2021


Background: Up to 30% of American adults may have unhealthy drinking behavior, but only 17% get screened. There is promise in improving screening via technology, but there is a lack of published evidence supporting these efforts. We describe the development of Automated Alcohol Misuse Interventions (ATTAIN), an automated, web-based process to screen for and manage adults with unhealthy drinking behavior with minimal involvement of health-care personnel.

Method: After creating a strategic business plan, ATTAIN was developed for the Southern California Permanente Medical Group using its integrated model of care, electronic medical records, and patient portal. ATTAIN is based on an automated branching questionnaire that screens for unhealthy drinking behavior and, when applicable, alcohol use disorders, and incorporates questions about readiness to change and interest in medications/counseling to assist with alcohol consumption reduction. Health plan members would be invited via email to fill out the screening questionnaire using the patient portal. Based on their responses, they would receive appropriate automated feedback and a link to a counseling video about the spectrum of alcohol use. Patients’ responses would be captured in their medical record and sent to a designated provider for further help as needed. The process would be refined through successive quality improvement pilots. We project that ATTAIN will lead to reduced costs for the Southern California Permanente Medical Group .

Conclusion: This effort has paved the way for using ATTAIN to improve patient care and to reduce the costs associated with managing unhealthy drinking, and potentially leads to similar processes for other medical conditions and health-related behaviors.


Excessive use of alcohol contributes to negative health, social, and financial outcomes for all age groups. In a 2015 National Survey on Drug Use and Health,1 it was estimated that 15.1 million US adults had drinking patterns that would qualify as an alcohol use disorder. Approximately 88,000 people die from alcohol-related causes annually, making alcohol the third leading preventable cause of death in the US. In 2010, it was estimated that unhealthy drinking behavior (also known as alcohol misuse) cost the US $249 billion. In a system attempting to avoid preventable morbidity and mortality while controlling costs, addressing alcohol use is an important initiative. Thus, the Centers for Medicare and Medicaid Services and the National Committee for Quality Assurance (NCQA) have recommended that health-care organizations incorporate alcohol screening as a quality measure (Healthcare Effectiveness Data and Information Set, or HEDIS).2

The most current accepted nomenclature for describing problematic alcohol drinking patterns can be found in the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), which uses the terminology “alcohol misuse (or unhealthy drinking behavior)” and “alcohol use disorder (mild, moderate, severe) 3.” According to the US Preventive Services Task Force, 4 alcohol misuse is “a spectrum of behaviors, including risky or hazardous alcohol use . . . . Risky or hazardous alcohol use means drinking more than the recommended daily, weekly, or per-occasion amounts resulting in increased risk for health consequences.” According to the National Institute on Alcohol Abuse and Alcoholism, “problem drinking that becomes severe is given the medical diagnosis of “alcohol use disorder.” Alcohol use disorder is a chronic, relapsing brain disease characterized by compulsive alcohol use, loss of control over alcohol intake, and a negative emotional state when not using.5 As of 2013, the DSM-V no longer uses the terminology of alcohol abuse or dependence. These terms now align most closely with the range of alcohol use disorders. Other terminology in the literature includes excessive alcohol use, hazardous alcohol use, unhealthy alcohol use, or problem drinking, all of which align with the spectrum of alcohol misuse and use disorders. We based our terminology on this current DSM-V nomenclature.

There is a long history of many different kinds of face-to-face strategies that have been implemented to address the spectrum of alcohol misuse and use disorders, including screening, brief intervention, and referrals. However they have proved costly and time-consuming. Far fewer studies, comparatively, have implemented digital or computer-based interventions to address unhealthy drinking behaviors. These initial studies have shown promise using short-term, multistage computer-generated personalized interventions for milder disorders or misuse. However, the majority of studies have focused on hospitals, community-based settings, and smaller population subsets (such as US veterans or college students).6-30

There is a gap in research covering computer-based programs that address unhealthy drinking behavior screening and intervention in integrated, managed-care organizations. Therefore, our study objective was to develop an automated, computer-based tool that screens people for unhealthy drinking behaviors and alcohol use disorders, and offers appropriate web-based counseling with minimal involvement of health-care personnel. This tool would be integrated into the electronic medical record (EMR)–patient portal interface of an integrated, managed-care setting. We named this tool Automated Alcohol Misuse Interventions (ATTAIN; previously named AAMIDRX, Automation of the Alcohol Misuse and Identification & Treatment, but we found the new name to be better for branding).


Integration Site

This project was developed for the Southern California Permanente Medical Group (SCPMG), which serves more than 4 million Kaiser Permanente health plan members. Of those members, approximately 2.68 million are adults, and thus are candidates for alcohol use screening.31 Based on the National Institute on Alcohol Abuse and Alcoholism estimates that up to 30% of the eligible population may meet the screening criteria for unhealthy drinking behavior, it is estimated that up to 800,000 of the eligible members served by the SCPMG may meet this criterion.1,31 For the HEDIS 2018 measurement year, health plan-reported data showed that 43% of eligible members had been screened, 5% screened positive for unhealthy drinking behaviors, and 27% of those who screened positive received documented follow-up.32

Strategic Business Plan

Stakeholder Analysis

The key external stakeholders were identified as the independent accrediting body (NCQA), the patients who would be screened, primary care providers, and addiction medicine providers. They are listed in Figure 1 and their strategic importance is highlighted in Table 1.

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Figure 1. Stakeholder map for the health plan implementing Automated Alcohol Misuse Interventions. CMS, Centers for Medicare Services; NCQA, National Committee for Quality Assurance (an independent accrediting agency).

Table 1. Stakeholder analysis for Automated Alcohol Misuse Interventions

  Public sector Private sector External agencies Primary care providers Addiction medicine providers Health plan affiliates
Who they are Health plan members Employer groups NCQA and CMS Contracted providers Contracted providers Other regions of the health plan
Role Patients receive the screening Contract with health plan for their workers Give health plan a score and accreditation based on quality Care for the HMO’s patients Care for patients with alcohol use disorders Offer services of similar quality as other regions
How they will be affected May benefit from treatment or may be annoyed by the screening Will appreciate more services being offered to their workers If they approve of ATTAIN, they may need to approve it for others May be spared extra work May have extra work added to their schedule May implement this plan if it works at their HMO
Potential contribution Compliance with the screening Continued use of this plan Approval of ATTAIN to meet their measures Awareness and support of the program if asked about it Readiness to treat those who need their care Demonstration of support by informing regulators
What they want Altruistic care at an affordable price Better health for their workers Improved health in participating health plans thanks to mandates Reduction in unnecessary work, enhanced effectiveness Reduction in unnecessary work, enhanced effectiveness Cost-effective ways to meet quality measures
Necessity of involvement Very high Medium Very high Medium Medium Low
Overall strategic importance High Low High Medium Medium Low

ATTAIN = Automated Alcohol Misuse Interventions; CMS = Centers for Medicare Services; HMO = Health Maintenance Organization; NCQA = National Committee for Quality Assurance (independent accrediting body).

Internal Analysis and Critical Success Factors

Competitive advantages included the SCPMG’s integrated model of care, EMRs, and patient portal, which together made ATTAIN possible. The necessary planning steps were 1) to make sure ATTAIN meets regulatory needs; 2) to design the patient interface in a clear, friendly, and nonjudgmental fashion; 3) to partner with addiction medicine; 4) to launch pilots, get feedback from stakeholders, and refine ATTAIN based on this feedback; and 5) to secure resources needed for long-term success. The critical success factor is the outcome of the program (the number of people who get screened and counseled). Successful outcomes should help us keep the program funded and give us the evidence to expand it.

Budget Assumptions

Expenses including the initial program development and maintenance costs (salaries, ATTAIN running costs, etc) are covered by the SCPMG. ATTAIN does not generate direct revenue and will be offered to the target population at no cost. Screening people via ATTAIN is expected to be less expensive than doing so via a doctor’s office visit. The cost of screening and brief intervention (using solely ATTAIN) is estimated at 10 cents/person (US dollars). The cost of screening and brief intervention in the traditional primary care office can be estimated based on the following assumptions and calculations:[(Cost per person assuming 1 minute of nurse time to screen and $60/h cost per nurse) (No. of members screened in the office in 2019)] + [(Cost per person assuming 2 minutes of physician time and $180/h cost per clinician) (No. of members who screened positive in 2019 and would require further screening by the physician)].33

If ATTAIN is successful as intended, it may help reduce the deleterious health consequences of alcohol use disorders by helping at-risk people reduce or stop their alcohol intake before they develop consequences. This may lead to further cost savings to the SCPMG.


The most important target audience of ATTAIN was the SCPMG, followed by the NCQA. Cost is a critical marketing factor because ATTAIN is expected to save money for the SCPMG compared to its alternative. Positioning messages included cost savings, measurable, convenient, and easy to implement. ATTAIN as a concept was presented to and received favorably by the SCPMG. To facilitate the SCPMG’s success with ATTAIN and to disseminate beneficial knowledge, the SCPMG entered into a 3-year, nation-wide collaborative effort with the NCQA, with the aim of improving unhealthy drinking behavior screening and follow-up. This has created a broader audience for ATTAIN as it proceeds through its design, pilot, implementation, and possible dissemination.

Risks and Mitigation

The top 4 risks were identified as outcome failure (inferiority to office-based screening rates), failure to address critical patient responses (eg, patients found to have alcohol use disorder during ATTAIN screening not getting the proper follow-up), regulatory failure (failure to get HEDIS credit for patients screened via ATTAIN), and patient complaints (about the ATTAIN process). Mitigation strategies for all risks were put in place, mainly via close collaboration with the key stakeholders. ATTAIN was presented to patient representative focus groups that gave helpful feedback to address potential concerns of patient privacy. A patient representative was also added as an integral part of our team to the NCQA collaborative.

ATTAIN Development

After receiving SCPMG executive leadership approval, our team worked with our EMR/information technology development team in concert with SCPMG leaders from addiction medicine and health education, as well as patient representatives. A branching questionnaire was developed following DSM-V criteria and using screening methods accepted by the National Institute on Alcohol Abuse and Alcoholism and US Preventive Services Task Force. Eligible members (18 years or older) would be asked the following two questions to screen for unhealthy drinking behavior (a diagram showing what qualifies as a “drink” is included as a reference for members):

1. “In the past year, how often have you had 4 or more [all women and men 65 years or older] or 5 or more [men < 65 years old] drinks in a 24-hour period?”

2. “In the past year, how many drinks do you have in a typical week?”

A response of “never” to the first question and a response of “7 or less” (all women and men > 64 years old) or “14 or less” (men < 65 years old) to the second question is a negative screen and ends the questionnaire. A response of “once or more” to the first question and a response of “8 or more” (all women and men > 64 years old) or “15 or more” (men < 65 years old) to the second question is considered a positive screen.

Positive screens automatically populate 12 additional questions to screen for alcohol use disorders, as well as questions assessing readiness to change, interest in medication, and interest in meeting with a specialist to assist in alcohol consumption reduction. ATTAIN scores patient responses based on DSM-V criteria for mild, moderate, and severe use disorders (Table 2). All responses would go to designated providers for further action as needed.

Table 2. Screening questions for alcohol use disorders, readiness to change, and interest in further help

During the past year how often . . .
1. Have you drunk more than you planned to drink?
2. Have you tried cutting down on your drinking but found it difficult to do so?
3. Have you found yourself spending a lot of time drinking or recovering from hangovers?
4. Had cravings or urges to drink?
5. Has your drinking affected your ability to work, attend school, or take care of your responsibilities at home?
6. Has drinking caused any conflicts between you and your family members or friends?
7. Have you noticed that you are not participating in activities that you previously enjoyed because of your drinking?
8. Have you driven any vehicle or boat, operated heavy machinery, or piloted a plane while “buzzed?”
9. Have you or someone else been injured because of your drinking?
10. Have you found that you keep drinking even though it is harming your physical health and/or mental well-being?
11. Have you found you need to drink greater amounts of alcohol to get the same effect as before?
12. Have you felt sick, shaky, or confused after you stopped drinking?
A. How interested are you in cutting back on alcohol consumption? (Choose one of the three following options):
“I am interested to know about what you can offer me to help me cut back” (questions b and c populate)
“I am not currently interested in cutting back” (questionnaire ends)
“I am working on cutting back and would like to do this completely on my own” (questionnaire ends)
B. Would you be interested to learn more about medications that can help reduce your desire to drink alcohol? (Yes or No)
C. Would you be interested in meeting with a specialist to discuss how you can reduce your alcohol use? (Yes or No)
Scoring for alcohol use disorders (range, 0–12) based on questions 1 through 12
0–1: No use disorder
2–3: Mild use disorder
4–5: Moderate use disorder
6 or greater: Severe use disorder

All participants who screen positive for unhealthy drinking are asked questions 1 through 12 and question A. Questions B and C depend on the response to question A. Automated Alcohol Misuse Interventions provides a score automatically for questions 1 through 12. For questions 1 through 12, answers are “Once or more” (1 point) or “Never” (0 point).

The implementation of the system was supplemented through partnership with key stakeholders—the Primary Care Department, Addiction Medicine Department, and HEDIS-related accreditors—to ensure that the system meets appropriate standards and that affected physicians would be aware and engaged in these changes.

Patient Portal–EMR Interface

ATTAIN works as follows: eligible health plan members are identified via the health plan based on age and an active account with the health plan’s internet-based, EMR patient portal (www.kp.org). An invitation email with the attached ATTAIN questionnaire link is sent to these member accounts. Members initially receive an email alert from the health plan, informing them of a care-related message on their account. They then follow the link in this initial email, which takes them to their portal, where they log in to their account. Upon successful login, they see the message (and a short video) describing the purpose of ATTAIN and asking them to complete the questionnaire. Patient responses become part of their EMR and are then sent to a designated provider’s in-basket (a unique EMR inbox for each provider).

Based on their responses, patients receive appropriate messages as well as an invitation to view a video about the spectrum of alcohol use. System analytics record how many individuals click the initial questionnaire link, complete the screening questionnaire, and open and watch the video. A repeat screening questionnaire can be sent later at a designated time interval to assess for a change in drinking patterns. If the individuals screen negative for unhealthy drinking behaviors, a reaffirming message is sent. Those who screen positive for alcohol use disorders get direct follow-up from a designated provider team (Figure 2).

tpj20141f2 copy copy copy

Figure 2. Automated Alcohol Misuse Interventions workflow.

Safety nets will be built into the system to attempt to catch individuals who do not progress through the algorithm. Reminders will be sent at set intervals, and there will be an appointed designated provider to oversee the process and monitor for gaps in the protocol.

Pilot Testing

ATTAIN was tested and refined by a series of quality improvement (QI) pilots, starting with a small number of members, with a plan to expand eventually to a region-wide application. As of this writing, the ATTAIN build and the first 3 QI pilots have been completed. Their results have been published in a separate article.36


Past studies have not explored the implementation of a fully automated system for unhealthy drinking behavior screening and follow-up (brief intervention) in an integrated, managed-care organization. This lack has paved the way for implementing ATTAIN, an automated tool for not only identifying, screening, and counseling individuals for unhealthy drinking behaviors using brief intervention, but also for identifying and screening for alcohol use disorders. We aim to navigate ATTAIN through the real world of health care, rather than a controlled research environment. Anticipated challenges include patient acceptance, completion of both screening and follow-up when required, and ensuring enough provider intervention when needed throughout the process, while reducing provider burden overall.

In an era when physician burnout is on the rise, this intervention has the possibility of offloading unhealthy drinking behavior screening from primary care providers who are tasked with a growing list of quality measures to meet at each health-care visit. The system may also see a decrease in costs through freeing up provider time, and through the appropriate screening and follow-up for unhealthy drinking behaviors and alcohol use disorders. Our work has the potential to guide momentum toward computerized screening and follow-up methods for other medical conditions and health-related behaviors.


Because ATTAIN was designed as a QI tool to be implemented in a real-life setting, there is no plan for randomization of members during testing. The QI team will be able to compare before-and-after results of ATTAIN on the broader member population. In addition, it is important to note that ATAIN currently excludes the pediatric population (younger than 18 years) as they do not have direct, unsupervised access to a patient portal. There may also be varied results based on the time of year, resulting from seasonal variation in alcohol use.34 Other policy changes and initiatives, such as promotion from “Mothers Against Drunk Driving,” may influence the results of this proposed intervention.35 Although the majority of the SCPMG’s member population prefers English, 10% prefer Spanish. There may be barriers for Spanish-speaking members to participate in the screening and follow-up, even if screening questions and brief intervention materials are offered in Spanish. As of this writing, the video describing ATTAIN, and the counseling video on the spectrum of alcohol use, do have Spanish versions. The ATTAIN branching questionnaire has not been translated into Spanish as of yet, but should be by late 2020. Those who are neither English nor Spanish speaking may not be able to participate, given that additional language options have yet to be offered. In addition, individuals may choose not to click the link for screening, and—even if they do—may opt not to fill out the questionnaire. If individuals complete the questionnaire and receive brief intervention materials (eg, the link to the video), they may not fully engage with the material, even if they do open it. Furthermore, this may be a sensitive topic to which individuals may not want to respond via a computer-based questionnaire, although previous studies have shown promise. It is also not known whether ATTAIN would work just as well if sent to members at random time points vs prior to upcoming appointments.

In the future, there may be options for better integrating the screening into the EMR through the patient portal—for example, by including the questions in a social history tab that automatically inputs into patients’ charts. Another consideration is to send the alcohol screening questions packaged in with other questionnaires (eg, drugs, domestic violence, and so on), instead of as a stand-alone questionnaire.


This clinical review was not submitted for institutional review board review and does not involve human subjects.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Author Affiliations

1Loma Linda University Medical Center, Loma Linda, CA

2Southern California Permanente Medical Group, Pasadena, CA

Corresponding Author

Mohamed H Ismail, MD, DrPH ()

Author Contributions

Mohamed H Ismail, MD, DrPH, participated in the intervention design, critical review, drafting of the final manuscript, and submission of the final manuscript. Jennifer Chevinsky, MD, MPH, participated in the intervention design, and drafting of and critical review of the final manuscript. Emma Fredua, MPH, CHES, and Ebonie M Vazquez, MD, participated in the intervention design and critical review of the final manuscript. All authors have given final approval to the manuscript.


The authors did not receive funding for this study.

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36. Yoon J, Fredua E, Davari SB, Ismail MH. The ATTAIN Solution Tested: Initial Pilot Results of an Automated, Web-based Screening Tool for Unhealthy Drinking Behaviors. Perm J 2021;25:20.143. https://doi.org/10.7812/TPP/20.143.

Keywords: alcohol misuse, automated screening, brief intervention for alcohol use, HEDIS measures, unhealthy drinking behavior


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