- How effective can physician EHR use prove without including non-primary care patient health data, especially behavioral health information?
That is one of several questions raised by researchers in a recent study in the Journal of the American Medical Informatics Association (JAMIA) investigating missing clinical and behavioral health data in primary care EHR technology.
"In this research, we found that the lack of integration, interoperability, and exchange in US health care resulted in a major EHR missing roughly half of the clinical information," Madden et al. write.
That conclusion includes both behavioral health data as well as information resulting from patient visits to specialty care providers.
"While behavioral health care is unique, it is important to emphasize that our findings demonstrate that the problem of incomplete clinical data in the EHR is not limited to behavioral care," the authors on to say. "Rates of missingness were high among both behavioral events and overall events, both in and outside the hospital. Specialist care of all types is particularly likely to be underrepresented in a primary care EHR."
Madden et al. compared data from a large physician practice and claims data from a health payer to evaluate the "missingness" of certain information from the primary care EHRs.
"When we linked data from both sources to match specific events across systems, the results were very similar: roughly half of the outpatient care days in claims could not be matched to clinical contacts recorded in the EHR," they write.
For 27.3 percent and 27.7 percent of patients with depression or a bipolar disorder, respectively, their primary care EHRs lacked a diagnosis of their mental illness. Additionally, despite the number of days these mental health patients spent in external, non-primary care settings, data about these encounters were generally underreported in their primary care EHRs.
The findings are significant given how and where patients receive mental health services:
While a broad range of specialty services is available at the primary site studied and some specialist care was documented in their EHR, roughly a quarter of current depression and bipolar diagnoses and more than half of behavioral visits were missing. Data missingness was similarly high for non-behavioral care, both inpatient and outpatient. Nearly 90% of acute psychiatric services at hospital facilities, representing more severe exacerbations of mental illness, were not captured in the EHR.
According to the authors, these findings have serious ramifications for effective physician EHR use.
"Published reports touting the anticipated benefits of the recent rapid adoption of EHRs," they authors continue, "should be tempered by frank examinations of EHRs as they currently exist. Above all, individual providers and health system leaders need to be fully cognizant of the information gaps and disconnects that lie behind the screen. Features that are intended to improve care and protect patients from harm may be inadequate in typical fragmented health systems, offering false comfort."
The features alluded to are the meaningful use requirements eligible providers are required to satisfy as part of the EHR Incentive Programs.
Madden et al. contend that policymakers ought to shift their focus away from functionality to utility and quality in order for physician EHR use to realize its potential. Also, they call in to question the development of health IT standards which the authors claim have favored EHR vendors rather than providers and patients.
"Federal policies to date have tilted too far in accommodating EHRs vendors’ desire for flexible, voluntary standards. The incompatible products that result undermine public health goals and can lock providers in to proprietary systems that cannot easily share data," they add.
Without the integration of behavioral health and other data sources into the primary care EHR, the authors foresee challenges for both providers and researchers alike — the former being handicapped in properly managing mental health patients (e.g., medications, monitoring) and the latter ill-equipped to perform epidemiological and evaluative studies of disease.