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Study: Behavioral Health Diagnoses, Visits and Hospitalizations Underrepresented in EHRs

April 15, 2016
by Heather Landi
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Electronic health records (EHRs) inadequately capture mental health diagnoses, provider visits, specialty care, hospitalizations and mediations, which could lead to medical errors, according to a study published in the Journal of the American Medical Informatics Association.

The study was conducted by researchers from the Department of Population Medicine at Harvard Medical School. The study authors concluded that given the fragmentation of health care and poor EHR interoperability, information exchange, and usability, “priorities for further investment in health IT will need thoughtful reconsideration.”

According to the researchers, recent massive investment in electronic health records (EHRs) was predicated on the assumption of improved patient safety, research capacity, and cost savings. However, most US health systems and health records are fragmented and do not share patient information, and this fragmentation and lack of interoperability and information exchange among the hundreds of EHRs systems currently in use leads to incomplete clinical data in EHRs, which can lead to medical errors, the researchers stated. And, researchers noted, there is very little published data on the completeness of medical information in primary care EHRs.

The researchers hypothesized that fragmentation and incomplete clinical data in EHRs might be especially common in mental health care, as patients may protect their privacy by seeking behavioral care at a separate location.

“Primary care physicians then not only run the risk of medication errors, but also miss opportunities to encourage adherence to mental health visits and medications. Treatment adherence is particularly poor among mentally ill outpatients and can lead to adverse outcomes, including hospitalization,” the researchers wrote.

For the study, researchers with Harvard Medical School’s Department of Population Medicine studied health insurer Harvard Pilgrim Health Care (HPHC) patients who were assigned primary care throughout 2009 to Harvard Vanguard Medical Associates (HVMA), a multispecialty medical practice serving more than 300,000 people in Massachusetts. Researchers focused on patients with at least one health insurance claim diagnosis of depression or bipolar disorder, which comprised 13 percent of continuously enrolled HPHC/HVMA adolescents and adults.

The researchers compared information available in a typical EHR with more complete data from insurance claims, focusing on diagnoses, visits, and hospital care for depression and bipolar disorder. As health insurers maintain claims data on nearly all drugs and health services received by a covered population, insurance claims can validate the completeness of mental healthcare data in provider EHRs, the researchers surmised.

Specifically, the researchers focused on diagnoses, outpatient and emergency department visits, and hospitalizations for depression and bipolar disorder, common conditions that may be treated with a combination of psychotropic drugs and ongoing outpatient treatment. The study examined the outpatient care visits, hospitalization and emergency department visits in claims and calculated the proportion of these visits not found in the EHR data, and conversely, also tallied all days of care in the EHR, and calculated the proportion of these that could not be found in the claims data.

The results of the study indicated that patients with depression and bipolar disorder, respectively, averaged 8.4 and 14 days of outpatient behavioral care per year; 60 percent and 54 percent of these, respectively, were missing from the EHR because they occurred offsite.

Total outpatient care days were 20.5 for those with depression and 25.0 for those with bipolar disorder, with 45 percent and 46 percent missing, respectively, from the EHR. Study diagnoses were missing from the EHR’s structured event data for 27.3 percent of patients with depression and 27.7 percent of patients with bipolar disorder.

Hospital-based events were also substantially underrepresented in the EHR. Among all acute psychiatric services in claims (594 hospital admissions or ED visits), 89 percent were missing from the EHR. Overall, 43 percent of all hospital-based events (hospital or ED, psychiatric and non-psychiatric) were missing from the EHR. By contrast, clinical events appearing in the EHR could be matched to events in claims in 93 percent to 98 percent of cases.

The study authors wrote, “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. 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. HVMA is a multispecialty provider group; we expect that in many other simpler primary care settings, the extent of missing specialist care in the EHR would be far higher than at HVMA.”

And, the researchers noted that EHRs have long been touted as a technology that will advance patient safety in the United States, and enormous public and private investment has been funneled into EHR development in recent years. According to data from the Office of the National Coordinator for Health IT (ONC, adoption of EHRs among U.S. office-based physicians increased from 48 percent in 2009 to 83 percent in 2014, though, the researchers stated, that “the extent of their actual use and effectiveness is unknown.”

“In this research, we found that the lack of integration, interoperability, and exchange in U.S. health care resulted in a major EHR missing roughly half of the clinical information. Policymakers should put more focus on the quality and utility of health information and ways these can be improved, instead of simply tallying up EHR purchases and supposed capabilities,” the study authors wrote.



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