iPad-based substance use screening reduces racial disparities in urine toxicology testing

Implementing a standardized iPad-based substance use screening tool on labor and delivery required months of institutional preparation — but the investment yielded measurable equity gains, according to Mariam Naqvi, MD, an associate professor of obstetrics and gynecology at Cedars-Sinai Medical Center in Los Angeles, California.whose work at Cedars-Sinai Medical Center was previously reported in part.

With the clinical findings and disparity reduction data covered in the first installment, Naqvi turned her focus to the practical realities of rolling out a protocol-level change across a busy academic labor and delivery unit—and what other institutions might learn from the experience.

Privacy was a foundational design principle.

"We really wanted patients to feel like they could answer the question safely, and so using something where they could fill it out privately was a major priority," Naqvi said. The iPad-based format was chosen specifically to address the limitations of verbally administered screening, particularly on a unit where patients are often accompanied by family members during sensitive portions of the admission process. "Ideally, when you're asking these sensitive questions, you're having the family members step out—but we know from a practical standpoint that's not always possible," she said.

Building the tool itself was a multiyear process. Naqvi credited her institution's informatics team as essential to the effort, noting that converting a paper-based screening framework into a functional, EHR-integrated electronic form took considerable time and iteration. The rollout incorporated a 4-month washout period to work through technical and workflow issues before data collection for the study formally began.

"It took months for our informatics department to develop the tool," she said. "Once it was developed, I would say it was pretty straightforward and it did go pretty seamlessly."

Staff education across all levels—nursing, residents, and attending physicians—was another prerequisite.

"Anytime you're implementing a new change that's going to require multiple levels of care, it takes time," Naqvi said. Institutions considering a similar approach should build in adequate time not only for tool development but for the educational infrastructure that supports consistent implementation.

Completion rates were high at launch, with chart auditing confirming the tool was completed more than 98% of the time in the early post-rollout period. Naqvi acknowledged, however, that enthusiasm following a new initiative can wane, and that ongoing monitoring of completion and refusal rates will be important to characterize longer-term uptake and patient experience. Formal assessment of how patients perceived the tool—including whether the format made them feel more comfortable disclosing sensitive information—is planned as part of future follow-up work.

"Our hope is that we're removing, coming back to the privacy piece, someone sort of asking you those questions," she said. "We do plan in some of our follow-up evaluation for this tool to assess what patients thought about the tool, how it made them feel, and whether it was something they felt comfortable filling out."

Reference:

1. Naqvi M, Tavakoli A, Thrift CS, et al. Impact of a substance use screening program on racial disparities in urine toxicology testing. Pregnancy. 2026;2(2):e70247. doi:10.1002/pmf2.70247